Shoddy Construction: Development Discourse and Chagas Disease in Southern Bolivia

Chagas disease, a parasitic infection of the blood and internal organs endemic to the Americas, plays a largely silent role in the lives of millions of rural people, from northern Argentina to the southwestern United States. Although present in the blood of upwards of 50% of the population (Médicos sin fronteras) in affected areas, and although this infection often leads to cardiac and intestinal failure, this plague receives little attention outside of the rural communities themselves.

Doctors without Borders (Médecins sans frontiéres, MSF) is a large international non-governmental organization (NGO) which defines its mission as twofold: providing necessary medical relief for underserved populations, especially in poor or war-torn areas; and advocacy on behalf of those populations served, both on the national and international stages.

In the department of Tarija, in southern Bolivia, these two narratives intersect. MSF (along with other NGOs, such as CARE, Plan International and Esperanza/Bolivia) is involved in an attempt to eradicate Chagas disease as a major cause of morbidity and mortality in the rural areas. This attempt generally consists of biomedical interventions in identification and treatment of cases[1] and pseudo-biomedical interventions (public health interventions) designed to improve housing conditions (by fumigating houses, plastering over thatched roofs and promoting household cleanliness) and thus prevent re-infection. In doing so, MSF involves itself in advocacy, which at least in this case has manifested itself mainly as “consciousness-raising” attempts, especially in the production of photographic expositions which have been shown in the major cities of Bolivia and inernationally.

This dual role for MSF presents an interesting opportunity for analysis, in which the “gaze” (as defined by Foucault in The Birth of the Clinic) consciously represents itself as the speaking subject, “I”. This involvement/detachment, inherent in the ambiguous position of the advocate as both observer and participant, provides the perfect opportunity for the observation of the “god-trick” as described by Haraway (and though certainly noted, the contradiction inherent in the observation and analysis of the “god-trick” risks unrestrained recursivity and is anyways certainly not within the scope of this paper).

MSF paradoxically presents itself as both the provider of “healthcare” and “development” (as understood within a decidedly Western context) and the voice of those who require its assistance, who are presumed unable to speak for themselves (or even completely voiceless). Within the framework of postmodern (or post-developmental) analysis, this seemingly contradictory stance serves to both preserve and mask the rigid power relations inherent in the positions of developer/developee (or, more specifically in this case, doctor/patient) and advocate/one-who-requires-advocacy. The advocacy both raises awareness of the problem and underlines the need (of representation) of the population, thus justifying its own existence. Meanwhile, this advocacy further justifies continued intervention, which, especially under a Foucauldian lens, serves to create the population to be “developed” as a discrete organism and subject of study. The constant reports, censuses and studies undertaken as the “baseline”, status reports and final achievements of the development project are incredibly self-justifying, constantly promoting the extension and deepening of intervention, all the while selecting, filtering and channeling the flow of subaltern voices and narratives, lending “authenticity” to the dominant narrative presented by the advocates themselves. This uninterrupted flow of information and further involvement preserves the hegemony of the “norm”, the “developed” and the “healthy”, defining its “target population”, inscribing its own boundaries and barriers around this population while pathologizing the living conditions of rural Latin Americans.

This self-evident definition of those in poor countries as “in need” preemptively blocks off any policy options other than those which can be seen as “top-down”. This limitation is in the best case a self-perpetuation of development discourse which is out of control (because it is out of view) of even the most powerful actors (in the view of Ferguson), or, in the worst case, a systematic and systemic perpetuation of current, unequal North-South power relations.

My note

In an effort to improve clarity and to elucidate the specificity of this paper, I pause here to clarify a few things. First, a note on the region studied: Tarija is the southernmost and geographically smallest of Bolivia’s nine departments, bordered on the north by the departments of Potosí and Chuquisaca and on the south by Argentina (Figure 1). It occupies a curious middle ground between highland and lowland culture and especially between what is thought of as Andean-Bolivian and lowland-Argentine. Recent exploitation of natural gas reserves in the eastern, lowland part of the department known as the Chaco has brought unprecedented wealth and growth to the department, though the rural areas remain extremely poor and are disproportionately affected by acute diarrheic diseases, malnutrition and Chagas disease. The department is sub-divided into six provinces and the provinces are further sub-divided into eleven municipalities. Tarija is also the name of the capital city of the department, lying in the municipality of Cercado, between the highland municipalities of Yunchará and El Puente and the valley municipalities of San Lorenzo and Uriondo. The area under study, however (for reasons explained below), will consist of the areas within a few hours’ drive of the city of Tarija, from O’Connor province in the east to Yunchará and Iscayachi in the west, and will also include one municipality of the bordering department of Chuquisaca, San Lucas.

This seemingly haphazard selection of sites is due to geographic similarities (the areas studied occupy a “middle ground” in Bolivia, neither highland nor lowland, ranging from approximately 1,000 to 3,500 meters above sea level, creating an environment in which Chagas disease is highly endemic), organizational peculiarities of the NGOs themselves (MSF is only active in O’Connor province, CARE restricts its activities mainly to the municipalities of Entre Ríos, Uriondo and Yunchará, and Esperanza/Bolivia operates in Iscayachi in Tarija and in San Lucas in Chuquisaca) and due to my own experiences in the area. During three months in 2006 I worked as an assistant to CARE’s Child and Maternal Health program (Salud Materna e Infantil, SMI), which is itself under the Sustainable Food Security (Seguridad Alimentaria Sostenible, SEAS) project, working primarily in the municipality of Uriondo, but also travelling with CARE to Narvaez (in Entre Ríos) and Yunchará and with Esperanza/Bolivia to Entre Ríos, Iscayachi and San Lucas, where I met with public health officials involved in their Chagas control programs. Being involved in work with CARE and Esperanza/Bolivia (as a translator/assistant to a visiting director), I did not make a systematic study of the region or the projects, though in making this paper I have referred back frequently to my own notes and photographs from the time, as well as doing research from the websites and publications of the NGOs themselves.

In constructing the arguments presented below, I frequently refer to different projects by different organizations as “essentially the same”, leaving the details of the differences between projects and organizational structures essentially unexamined. Beyond academic laziness, this is due to practical and theoretical concerns. First, it would be impractical for research of this level to concentrate on one organization, as including more NGOs, while obscuring details, provides a more complete view of development in and around Tarija. The essential similarity I intend to study is the discourse emanating from these organizations to the population, depicting this population as, variously, “in need”, “under-developed” and “diseased”. Furthermore, the uniqueness of MSF’s explicit attempt at advocacy, though not necessarily their on-the-ground programs, provides and interesting facet for analysis of this kind, which will be compared with the discourse surrounding their Chagas control programs and the programs of other NGOs.

Finally, I leave the interaction between the communities and the NGOs only half-understood, creating a facile binary between developers and developees, ignoring the re-depiction of development discourse within and between communities and implicitly assuming a uniform response to and return on a given development project, which is emphatically not the case.

I want it to be clear that in writing this paper I am not condemning wholesale the projects under study or the organizations cited, and I am certainly not ascribing to them motives other than those expressed by the organizations themselves. Having lived and worked with people representing these organizations, I know that they work with the best intentions and with a common goal of eliminating poverty and increasing health, in the broadest sense of the word. I have never witnessed anyone working for any of these organizations treating the people of the rural communities mentioned with anything but the utmost respect and dignity. I do, however, believe that the fundamental beliefs and assumptions of these organizations in many ways perpetuate the inequalities that are so universally denounced. In writing this paper, I hope to illuminate a few of the processes by which these unequal power structures are reproduced.

Theoretical groundings

Critical development theory, which will be referenced (often indirectly) throughout this study, has emerged through the interaction of a number of ideologically distinct movements. Until the early 1990’s, studies of development could generally be divided into two strands (Ferguson 1994): those who studied (and supported) development with an eye towards fixing its shortcomings (Hirschmann 1967, Robertson 1984, etc.) and those (often identified or self-identified as neo-Marxists or dependency theorists) who saw the development project as a continuation of colonialism and essentially a tool at the disposal of Western elites to continue their control over large swathes of the “Third World” (Escobar 1995 is an excellent later example of this school of thought). Later theorists (such as Ferguson 1994, though this school is explained further below) have applied insights from poststructural (discourse, especially) theory to the production and reproduction of unequal power relations, as generated by the development project itself.

The term “development” itself is problematic, implying a natural and unyielding progression from the “un(der)developed” to the “developed” (Esteva 1992: 7). This binary between “developed” and “undeveloped” in many way mirrors the colonial (and neocolonial) discourses, framing an Other which is inherently marked (or particular) (see Haraway 1991) and inferior (see Said 1978). Further post-colonial (though not necessarily post-development-al) critics point out the problems of representation/re-presentation of the always-already known and marked colonial/feminine/subaltern Other in Western colonial discourse, implicitly drawing parallels to present-day attempts at advocacy and intervention (Spivak 1988). The common thread of this argument is that

knowledge [so as to better help/serve the ‘less fortunate’ Other] is always imbricated with power, so that getting to know (or ‘discursively framing’) the Third World is also about getting to discipline and monitor it, to have a more manageable Other; and helping the subaltern is often a reaffirmation of the social Darwinism implicit in ‘development’, in which ‘help’ is framed as ‘the burden of the fitest’ (Kapoor 2004: 632).

Spivak further criticizes the “worlding” which discursively separates the “Third World” from the “West”, disavowing the complex relationships and histories of imperialism, co-optation and general continuous historical interaction (1988: 291).

Other critics of the development project have constructed their analysis around causes and effects, attempting to understand the discursive and institutional mechanisms that seemingly doom humanitarian intervention to ultimate failure. Ferguson (1994) sees the ultimate depoliticization and bureaucratization of development projects in Lesotho as a side effect (which ultimately overshadows the intended effect) of institutional policies and structures which privilege the production of “expert” knowledge and the re-production of development discourse over the eradication of the conditions which necessitate their existence. The branding of “development” as a “technical problem” in this sense (how to maximize the effectiveness of the current policies and strategies) prevents aid agencies from addressing the fundamental discursive and politico-economic practices which result in inequality.

Still others draw more directly on the work of Foucault in explaining development as a problem of “normalization” and “apparatus (dispositif)” (Brigg 2002: 421). Brigg draws heavily on the governmentality literature in explaining the use of knowledge as power (see Kapoor, above), as opposed to relying on facile references to the “colonization metaphor”, seeing the operation of power through development as much more diffuse and complex than can be understood when “some post-development writers…overly aggregate the operation of power, to ascribe intentionality to a singular historical force such as ‘the Americans’” (433).

These theoretical points of departure will inform my study of the production of representative economies in the discourse of development agencies in southern Bolivia. I hope to show how the production of knowledge (and the assumption of knowledge) has led to the re-production of unequal power relations between developer and developee. However, before that study can commence, a short explanation of Bolivian politics (and how they are formed and informed by the governmentality and critical theory literature) is necessary.

What they mean when they say “neoliberalism” in Bolivia

Bolivia’s experience with neoliberalism (as both an ideological and a political-economic ideal) has been in many ways unique. Overwhelmingly, the term is used in reference to the economic policies of the 1980’s and -90’s, especially under the direction of Gonzalo Sánchez de Lozada, either as planning minister under Víctor Paz Estenssoro from 1985 to 1989 and as President from 1993 to 1997 and from 2002 to 2003. “Neoliberalism” has become a byword for structural adjustment programs, privatization of state-run industries and the entrance of multinational corporations into the Bolivian economy, as it has become a rallying cry for leftist political parties and movements. Bolivia’s unique history and experience with neoliberalism leaves the term nearly completely disconnected from the post-structural (ideological) meaning used by Rose and others, though important links remain.

Jeffrey Sachs chronicles in his book Bolivia’s first experience with the “shock therapies” to introduce the country to economic liberalization. Massive inflation (24,000%, the highest in the world in 40 years) in the early 1980’s due to government fuel subsidies coupled with a regional economic crisis and the collapse of mineral, especially tin, prices caused enormous destabilization of the economy, prompting the measures which rapidly removed all price controls on the Bolivian currency and subsidies on various products ranging from food to fuel and mineral resources. This initial program and those to come later, enacted under Sánchez de Lozada and others (Jaime Paz Zamora, Hugo Bánzer and Jorge Quiroga) included the liberalization of Bolivian markets, allowing extensive foreign investment in state-run industries, selling off such companies as the Bolivian Fiscal Petroleum Deposits (Yacimientos Petrolíferos Fiscales Bolivianos, YPFB), the state-run gas company, which was essentially dismantled under the reforms (which would provide a source of political discontent in the coming years). These policies, in the longer term, have had mixed results, allowing Bolivia a minimum of economic stability to grow generally through the 1990’s (Sachs et al 1988; Schroeder 2000), but also generally adding to the political instability while doing little to reduce poverty (especially among the poorest of the poor) or inequality (Crisp & Kelly 1999; Schroeder 2000).

All of this it not to say that these re-forms have made Bolivia a thoroughly neoliberal state, though significant strides have been made in that direction. Neoliberalism, as understood by Rose (1996a, 1996b) through the literature on governmentality (stemming from Foucault’s seminal lecture (Foucault 1991)), requires the re-conception and re-figuring of the individual as an active agent of their own government (meaning here personal behavior), seeking out those activities, behaviors and conditions which would most benefit them and, through the collective, become a “public” good. The Bolivian government has always had to contend with multiple, thoroughly overlapping identities among the people within its borders, representing workers’ groups (miners’ unions, coca-growers’ unions, teachers’ unions, etc.), ethnic groups (Quechua, Aymara, Creole, etc.), geographically-located identities (camba (one from the lowlands) v. kolla (one from the highlands)) and socio-economic classes (rural peasant groups, participants in the “informal” urban economy, the wealthy urban and rural upper classes and the growing urban middle class). In fact, nearly every term used to designate a particular identity in Bolivia (campesino, cholo, indio, camba, kolla, etc.) has been appropriated and re-appropriated by both those who denounce that identity and those who claim it as their own. This startling multiplicity of identity has complicated political and social interventions, though generally (and especially recently, since 2003) government programs of social inclusion and “capacity building” among various identity groups have prevailed. This “re-figuring” of the political landscape away from a hegemonic, solidarity-inspiring conception of the “national”, the “Bolivian” or the “society” (“as a whole”) mirrors quite closely Rose’s (1996a: 333) conceptualization of the formation of the neoliberal project around “communities”. These “communities”, however defined, have become the privileged site of government intervention, going so far as creating territorial-based organizations (organizaciones territorales de base, OTBs) under Law of Popular Participation of 1994, tightly defining rights and privileges of rural indigenous communities (especially around the Quechua ayllus of highland Potosí department) and giving them a measure of autonomy in their own territory. As they were enacted under a government which later went on to brutally suppress indigenous uprisings in February and October 2003, these reforms can be seen in hindsight as a cynical tactic to exclude through co-optation the political power of the majority of Bolivians (over 60% are identified as “indigenous[2]”), though it must be said that the reform was promulgated in response to growing calls for inclusion of indigenous, especially Aymara and Quechua, political systems. Interestingly, until the current presidency of Evo Morales, reforms of this nature were generally demanded first by the explicitly ethnic or geographical groups and were strongly resisted by the central government, which preferred to preserve the “single matrix of solidarity” (Rose 1996a: 333) of a more socially-based territory. It seems that the Bolivian population has generally led the state in the move towards ideological (though certainly not economic) neoliberalism, creating an intricate and often paradoxical theoretical landscape.

Naming names and making space; or: Is it better to give than to receive?

Rural highland Bolivia is by and large only accessible with difficulty, over poorly-maintained dirt roads and with a 4-wheel-drive vehicle. The roads between the small communities are poorly marked. Outside of every community, however, there are cement-block signs, whitewashed and painted with the name of the community, the names of the organizations supporting projects there and the projects themselves, as seen in Figure 2. The sign shown is found in the community of Antigal, about an hour and a half by jeep from the city of Tarija, in the Municipality of Uriondo. Similar signs dot the roads branching out in all directions from Tarija, usually the only markers for the turnoff onto the dirt tracks snaking up the walls of the valley into the communities themselves. The two most common types are from CARE’s SEAS program and from Plan International. Though CARE is a traditional development NGO and Plan International is ostensibly a child sponsorship organization, their projects in the region are essentially the same: basic infrastructural improvements (drinking water, irrigation and road improvements) and public health interventions dominate. With few road signs marking routes and even fewer announcing the presence of a rural community, NGO signs are the landmarks around Tarija.

What does it mean to know a community by the NGO projects in operation there? First, we must see who is doing the naming. It is the NGOs, of course, who erect these signs, though certainly with the participation (and most likely the labor) of the communities themselves. A sign is erected once a certain level of participation (which usually involves regular meetings, the designation of community representatives, and some material donations) is achieved, designating that a convenio (agreement) has been reached, enumerating precisely the shortcomings in the development of the community and stipulating certain responsibilities for both the NGO and the community. The sign then is a physical symbol of the contract, which, while constructed through the cooperation of two parties, leaves little doubt about the roles of the participants. While the NGO has clearly donated the bricks, mortar and paint, the community contributes labor, both in the actual construction of the sign and in the more intangible agreement to work with the NGO, and, in a sense, for the NGO. The symbolic roles of developer/developee (material-and-direction/labor), giver/receiver (active/passive) are reinforced, defining the communities not only by their needs (as is written in neat block letters on the sign), but also by others’ responses to their needs. In other words, these communities are only known and named by and through the agency of those outside actors, reinforcing the boundary between who is being served (and I intentionally use the passive voice here) and who is doing the serving.

All of this is not to say that CARE (for example) is being dishonest when it speaks of the desire for dialogue between community members and CARE representatives. CARE fieldworkers are in constant dialogue with the people of their assigned communities about the problems faced and possible solutions, and CARE investigations rely heavily on dialogue and participation in evaluating past projects and proposing new ones. These predetermined roles do, however, limit both the range of topics discussed and the possible solutions expressed. Ultimately, projects are conceived and incentives are decided upon in the offices in the cities, limiting the actual discussion at the monthly meetings to a negotiation of the timeline, the methods of evaluation, and, more basically, whether or not the proposed recipients of the aid will accept.

I discuss these signs by way of synecdoche, as one manifestation of the identities ascribed to and by aid organizations and communities in the region. Rural communities, the self-apparent primary units for developmental intervention, are named and described by the NGOs, studied under the rubric of development to discover the faults that require attention. In defining their units of study, aid organizations shield their own organization, their unique cultural practices and more generally their own specificity from the analytical gaze. As in Foucault’s account of the production of biomedical knowledge (Foucault 1963), developmental knowledge cannot be questioned because its origin is obscured, said to stem from the impartial analysis of the “undeveloped” themselves, while the processes and practices of those producing the knowledge are themselves presumed universal. The “undeveloped” are the specific and partial Others, while the developers remain the universal Norm. Thus the “target population” (which will be referred to without quotes throughout the remainder of this essay) is constituted as both external to the idea of a homogeneous “developed” world and as a necessary object of study, analysis and intervention for this unmarked development project, which can then assume the mantle of flowing naturally from a self-evident “need” towards an equally natural and universally desirable “development”.

Advocating for the Others

This binary division, and all that it implies (powerful/powerless, active/passive, giver/receiver, etc.), is fundamental to the concept of advocacy. In implying the powerlessness of those on whose behalf it speaks, MSF structures the discursive options available in its crusade, unintentionally (one would assume) reinforcing the powerlessness of its beneficiaries by portraying them as needy and thus unable to participate with full agency in their own “development”. MSF’s advocacy campaign in this case has taken the form of a photographic exhibition which has toured within Bolivia and abroad. The full exhibition consists of more than thirty black-and-white images, though in this analysis I will concentrate on the eight photographs (Figures 3-10) available freely on the website of MSF’s Spanish branch (Médicos sin fronteras: “Visita virtual”) because of the difficulty and time involved in gaining access to the remaining photographs. It must be mentioned that the two formats have distinctly different intended audiences. The free exhibition which I viewed in La Paz in 2006 was mainly attended by the middle classes of La Paz, who are understood to have a certain knowledge of the regional context of the images, viewing the people portrayed as more mundane than exotic, a byproduct of the inequality which has produced the viewers as comfortably wealthy while producing the objects of the photos as miserably poor. Viewers abroad, however, are not expected to feel the same affinity or even to recognize any connection as part of the same political economy. Outside of the Bolivian context (which is not itself entirely homogeneous), these images portray the exotic, impoverished Other towards whom the viewer is expected to feel pity. For example, in the eight photographs presented there are six women shown. Of the six women, the only ones to appear in “Western” dress are the ones clearly identified as employees of MSF, while the other three all appear in dress which is typically characterized as “traditional” to southern Bolivia. In that women are often portrayed as the guardians of “traditional values”, here they can be seen as serving as symbols of the adherence to “tradition” in Bolivia. The images imply the distinction between “tradition”, disease, and underdevelopment in rural communities on the one hand and “modernity”, health and development as brought by MSF on the other[3]. Beyond merely implying a division between active subject and passive object in the existence of the advocacy program in itself, MSF underlines and reinforces this distinction through its portrayal of rural Bolivians in the eight photos selected for electronic distribution. In none of the photos is someone readily identified as a member of the community (i.e. not wearing clothing marking the person as a worker for MSF) portrayed as an active participant in the fight to rid the area of Chagas, and every time an MSF worker appears, she or he is portrayed as actively teaching about, diagnosing or treating Chagas disease. Though MSF makes a case for the active participation of the target population in its interventions, its discourse of advocacy systematically denies and excludes any agency except that exhibited by those working explicitly through its own organization.

While MSF is the only one of the four NGOs under study which has attempted to advocate on behalf of those who suffer specifically from Chagas disease, every organization has used advertisements and media campaigns, hoping to raise funds by raising awareness. Plan International (and subsidiary organizations Plan USA and Plan Bolivia) uses language specifically relating to the participation of the communities in which they work, aiming to “enable[e] deprived children, their families, and their communities to meet their basic needs and to increase their ability to participate in and benefit from their societies” (Plan International: “Plan Bolivia”), while “help[ing] communities develop, grow and, ultimately, support themselves” (Plan USAa). Their rhetoric is distinctly hands-off, though reading through their programs, especially the Chagas control program, PROPLAN (Plan USAb), it becomes apparent that the locally-led approach is meant to apply more directly to the funding aspects, where the programmatic side of the project is centrally determined, with the implication that they are merely enacting the only logical course of action: “The Chagas Disease Control Program (PROPLAN) is based on the experiences of Plan Bolivia and Pro Habitat” comes as the only explanation of the development of the program itself, while this methodology is justified by the fact that “the funding has evolved from being almost completely externally supported to being 75 per cent locally funded[,] demonstrate[ing] that the program is on its way to sustainability and is highly regarded by the communities” (Plan USAb). Furthermore, while it ascribes 75% of the $11m of funding to “local” sources, $4.5m is provided by the central Bolivian government through the Vice Ministry for Urban Development and Housing (Viceministro para Desarrollo Urbano y Viviendas, VMDUV) and a further $400,000 to the Bolivian NGO Pro Habitat, totaling $4.9m (or nearly 45% of the total). Of the remaining 30% of funds, 92% is donated by the communities themselves by “provid[ing] local materials and labor valued at over $3.2m” (emphasis mine), meaning everyone is employed in improving their own houses and carrying the cane and stones necessary for this task, but implicitly excluding the communities from a “modern” cash economy on the basis of their poverty or being “undeveloped”.

CARE’s publicity campaigns (which, like MSF’s, are explicitly termed “international advocacy”) have centered more directly on subaltern empowerment, especially empowering women and girls to participate more fully in the decisions affecting their lives and thus improve their own lot in life (this mission itself being explicitly neo-liberal in its basic ideology, though that is a topic for another essay). In the “I am powerful” campaign, CARE USA, describes its mission as

empowering women around the world to be catalysts for change in their communities…CARE tackles underlying causes of poverty so that people can become self-sufficient. Recognizing that women and children suffer disproportionately from poverty, CARE places special emphasis on working with women to create permanent social change. Women are at the heart of CARE's community-based efforts to improve basic education, prevent the spread of HIV, increase access to clean water and sanitation, expand economic opportunity and protect natural resources” (CARE USAc).

The advertising campaign, consisting of women in various forms of “traditional” dress staring proudly into the camera, asserts the power of the women to positively affect their world (Fig. 11). This campaign, however, echoes clearly the same exoticizing tendencies of the MSF campaign described above. Of the roughly dozen women appearing in the flash presentation (CARE USAa), two are shown in Western dress, and again, both are wearing clothes clearly identifying them as working directly for CARE. Apparently CARE’s work is to rescue women from the “traditional backwardness” holding them back, and only through CARE can they become “modern” and thus empowered. Through this approach, one can clearly see that

[e]mpowerment, with all its emphasis on strengthening the capacity of the individual to play the role of actor in his or her own life, has come to encompass a range of interventions to transmit, under tutelage, certain professionally ratified mental, ethical and practical techniques for active self-management. Under the sign of empowerment, one thus can observe the re-deployment of the whole panoply of psychological technologies for reforming conduct in relation to particular norms, from individual psychotherapy in various rational and cognitive forms, through the use of programmed behavioural techniques to group work (Rose 1996a: 348)

Though Rose speaks of “empowerment” more in terms of back-to-work programs or psychological help for inmates, important similarities can be seen with “empowerment” as a tool of international “development” and general social integration with the aim of lessening inequalities. Here, empowerment acts as a disciplinary tool, integrating these women into a cash economy and promoting “universal” (neo-liberal) ideals of human rights. These women and their societies are clearly measured against a yardstick reflecting Euro-American priorities and ideas of “progress”.

Esperanza/Bolivia’s discourse (as shown by the discourse of their parent/principal donor organization, Esperança, Inc.) is by far the least interested in meaningful participation in the conception and execution of the projects. In her column “Kelli’s Corner” in the November 2006 Esperança, Inc. newsletter, program director Kelli Donley writes of her first visit to Bolivia earlier in the year, describing an “intense, beautiful country” populated by people who are “sweet-natured and curious” living “simple lives as farmers and herders”. Donley clearly implies a nearly unbridgeable rift between her readers, American donors to Esperança, Inc., and the Bolivian population living in what is presumed to be a largely “traditional” society. In continuing, she states matter-of-factly: “parents know that indeed, because of the kindness of strangers, their children will grow to lead happy and healthy lives” (emphasis mine). Here, the agency of rural Bolivian parents in the positive development of their children is completely denied, as the absolute necessity of humanitarian aid (specifically, aid from the “developed” people of the United States) to “save” the country is made abundantly clear.

In analyzing their own publications, I hope that I have highlighted differences as well as similarities between MSF, Plan, CARE and Esperanza/Bolivia. While there is a great range in the amount of attention paid to community involvement and agency (with Plan, CARE and MSF all emphasizing the role of the community in their projects and Esperanza/Bolivia emphasizing the necessity for outside agency), I have shown that each organization’s approach is based on a fundamental, presupposed inequality and the “need” of the target population (which is in fact constructed by the very discourse which seeks to describe and analyze it) for assistance which is both externally mobilized and externally planned.

The sick house

In spite of their different formulations of the problems of (under)development, CARE, MSF, Plan and Esperanza/Bolivia all undertake remarkably similar[4] public health interventions in the rural communities in which they work. While CARE does not in fact provide Chagas treatment (though it does facilitate treatment at local clinics), the other three organizations all undertake regular diagnosis and treatment campaigns, coupled with the improvement of housing (mejoramiento de viviendas, MV) (Figures 12 and 13), cleanliness campaigns and the fumigation of houses and the immediately surrounding area (CARE does participate to a degree in these activities, especially the cleanliness campaigns).

Interventions such as these have a number of very distinctive ideological foundations. Fundamentally, they are based on a positivist, neo-liberal worldview, in which individuals (and those closest to them—families and communities) are taken to be the self-evident, logical and always-already existing units of the population, and thus are the preferred sites for intervention. From this ideological base stem the twin programs of biomedicine and development, with the realm of public health existing somewhere in-between. They both (or all three) depend on conceiving the world as essentially ranked and ordered, with individuals and communities (and bodies) moving smoothly along a continuum from undeveloped (sick) to fully developed (healthy). In this understanding, the categories of healthy and developed are taken to be natural and obvious while the categories of sick and undeveloped are seen as problematic and worthy of study to “see what is wrong with them”, or why they can’t just be as healthy and developed as the rest of us. This division creates a clear Norm/Other binary, leaving the Norm (developed, healthy) as both unexamined and unchallenged. In other words, in trying to understand why they aren’t more like us, we forget to ask why we aren’t more like them.

MV programs of the type employed by MSF, Plan, CARE and Esperanza/Bolivia rely on this uncontested construction of the Other in their conception. In exactly the same way which Foucault describes the construction of deviance as “unhealthy” or “pathological”, a Norm of housing standards (and those unhealthy or pathological conditions which fall below standards) is created and enforced in the cleanliness and MV campaigns. In these interventions, the place of rural communities as junior partners (if at all) in their own “development” is seemingly “proven” by what is interpreted as a previous lack of agency in improving their living conditions, thus necessitating assistance from external organizations.

The constant studies, censuses, meetings and investigations further cement the rural communities firmly in the realm of the object of knowledge, allowing development agencies to assume untroubled the role of subject (producer) of knowledge. As a subject, these NGOs remain uncontested because their existence is made to be beyond dispute, an uninteresting (because obvious) topic for study. Again, the subject/object dichotomy, mapped neatly onto the rift between Norm and Other, underscores the lack of agency of the rural communities themselves and overemphasizes the necessity for the agency of aid organizations.

Conclusion; or: what I didn’t mean to say

This is an excellent place in the paper to place this study in the context for which it was intended. It has been seen above that many of the programs, and especially the public representations of such programs, enacted by NGOs in southern Bolivia actually serve to reproduce the unequal power relations which they purport to address. I fully recognize that I haven’t done a full analysis of the effects these programs have had on the target populations and the societies as a whole as they exist in the area. Nor have I properly researched the dynamics of the production of these projects, leaving the projects to “speak for themselves”. I have attempted to place the projects themselves in the regional context, with a distinct look towards the identities assumed and the identities created by the discourse used.

With a more prescriptive view, I do not believe that it is completely necessary or even possible to work “outside” of the power structures that create the actors involved. Assuming that one was working outside of power structures would require assuming absolutely impartiality of knowledge, an oxymoron if one were to believe in the cultural, partial production of knowledge. I write this essay as a means of properly situating the knowledge created by the programs and working through their partiality towards an end goal. The reproduction of power structures need not be an endless, repetitive and negative process. Even processes reproducing the subject/object or Norm/Other binaries as described above are able to achieve, in certain instances, what can be interpreted as a “good”: access to clean water, lower rates of Chagas infections and increased income. Further study placing the communities described into the category of primary agent will reveal that even subaltern communities retain a high level of agency, affecting not only their own immediate conditions, but also the conditions of a larger, national society.

This was not a study of Chagas disease, nor was it a study of developmental “intervention” per se, nor was it an explicitly political call for more Chagas research to find effective and safe treatments for this disease (though that would certainly be warranted—the current drugs are only safe to use with adolescents and are relatively ineffective). This is not to say that none of these would be legitimate topics for study, in my opinion, but that a deeper thread, the development organizations’ construction of their “target population”, runs through all these and must be considered. I have used Chagas disease as a convenient point of departure (from which it seems I have strayed), investigating instead the actions and rhetoric stemming from those committed to eliminating it from southern Bolivia. I find that their discourse consistently constructs those of their target population as lacking the necessary agency to improve their conditions, incorporating them as junior partners, if at all, in their own lives. This discourse has its uses, raising funds and in many ways bolstering the position of the NGOs and facilitating their interventions which often bring concrete benefits to many “underserved” populations, but it also reproduces the power structures responsible for the conditions in the first place. In order to (more) fully break free of this cycle, knowledge stemming from aid organizations must be fully situated, removing the NGOs as the privileged, unmarked and hence unscrutinized, fountain of knowledge. In this way, by marking both (or all) parties as knowable objects (in addition to subjects of knowledge production), power structures can more easily be analyzed and accounted for (rather than completely dismantled). Truly, the problem of “development” in the Third World (as framed by the developer/developee binary) can only be overcome by removing “development” and its discursive baggage from the equation.

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[1] Ineffectively—Chagas’ disease is able to “hide” in the blood of adult hosts, and pharmaceutical treatments are considered prohibitively dangerous in patients under 6 years of age and above 15 years.

[2] I will continue to use the term “indigenous” throughout this section without quotes. I understand that the term cannot be used unproblematically due to its history in the service of colonialism, but I want to make the distinction that here I am using the term in the Bolivian context, in which “indigenous” has come to represent an explicitly political identity (though not necessarily a homogeneous one), and it is that invocation of a (possibly imaginary, but immensely powerful) political identity which I would like to convey.

[3] In this discussion I have noted the difference between the women of the photos and not the men. I have chosen to focus on only the women because I believe that the differences in dress are much more apparent to the uninitiated viewer, while the differences in masculine dress are much more nuanced.

[4] So similar, in fact, that I will not attempt to distinguish between the different outcomes of the different positions which have been detailed above. Plan, MSF and Esperanza/Bolivia are all involved in direct action against Chagas’ disease, with CARE involved more tangentially (it never refers to its programs as directly treating Chagas’ disease, but its cleanliness and home improvement campaigns all address issues directly related to vector control). Of the three directly involved, each one provides diagnosis and treatment for Chagas’ disease when and only when an effective program of vector control has been undertaken in the community, involving fumigation, the sealing of cracks in houses, the improvements of roofing materials and intensive monitoring of reinfestation by the vinchuca.

Figure 1. Municipalities under study in Tarija and Chuquisaca

Figure 2. Sign at the community of Antigal, Municipality of Uriondo, Tarija, Bolivia
Translation: Prefect of the department/Community: Antigal/Irrigation system – literacy (lit.: “literacization” or “causing to become literate”)/Benefiting families: 69/Agreement: DRIPAD (Desarrollo Rural Integrado y Participativo en Áreas Deprimidas, Integrated and Participative Rural Development in Deprived Areas) – community/Conserve the wild flora and fauna)

Figure 3. Photo showing the interior of a home before improvement (MSF)

Figure 4. Taking blood samples to test for Chagas disease (MSF)

Figure 5. Children being taught to identify the vinchuca, the vector for Chagas disease (MSF)

Figure 6. Fumigating a house (MSF)

Figure 7. Health workers teaching community members about Chagas disease (MSF)

Figure 8. MSF worker taking a blood sample during a treatment campaign (MSF)

Figure 9. MSF worker administering treatment to a child with Chagas disease (MSF)

Figure 10. Laboratory worker testing captured vinchucas for the Chagas parasite (MSF)

Figure 11. A sample image from CARE USA's "I am powerful" campaign (CARE USA)

Figure 12. Interior improvement of housing

Figure 13. Exterior improvement of housing

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