High Prices, Poor Access

In remote areas throughout Bolivia, when a person becomes ill, he or she most likely will turn to traditional remedies. The reason is a practical one: traditional remedies are affordable, and the costs of modern health services often are not. For most subsistence farmers, paying a doctor's fees or even purchasing aspirin is simply beyond their means. On the other hand, a typical kallawaya prescription may be the preparation of a tea infusion made from plants the farmer probably already has on hand. The most common compensation for a kallawaya's treatment is the exchange of goods or other services.

But even more important than the cost issue is that of accessibility. In rural Bolivian villages, there often are no doctors, nurses or medical posts. Townspeople rarely have a choice-the only health interventions available are those offered by traditional healers.

"Public health services do not reach that far into the countryside," says Dr. Carlos Linger, who heads Bolivia's office of the Pan American Health Organization (PAHO) in La Paz. "The presence of the kallawayas and their medicine provides people with a feasible alternative."

Alipio Barrera, a youthful kallawaya of 25, would agree. "Doctors really don't go where we do. We set out several times a year, for one to four months at a time, trying to visit as many communities as we can. We almost never come across doctors in these places."

The kallawayas continue to travel on foot, just as they did centuries ago, despite modern means of transportation. "The roads are getting better now," says Suxo, "but when you're out looking for people who might be sick, it is always better to go from place to place on foot."

The sight of a kallawaya medicine man, wearing a brightly colored hand-woven poncho of vicuña and his lluchu (knit cap), wending his way along the crooked path with his walking stick, is a common one in the Bolivian highlands. "They spot our clothes from far away and know that the kallawayas are coming," Barrera says.

Of Medicine and Mangoes Deep in the highlands of Guatemala, Médicos Descalzos, a French nongovernmental organization, is working with the Pan American Health Organization (PAHO) to better the health and living conditions of the numerous indigenous groups living in the departments of Huehuetenango, El Quiché, and Baja Verapaz. The innovative Medicinal Plants project is not only reviving interest in the value of traditional medical wisdom and techniques, but also extending the coverage of primary health care. More than 1,500 rural health promoters and public health practitioners, as well as hundreds of indigenous women, are being trained in the use of 26 medicinal plants commonly found in Guatemala whose therapeutic properties have been proven scientifically to prevent and/or treat the 10 most common digestive, respiratory, and skin disorders affecting the majority of the area's residents, as well as a host of other maladies. The list includes annatto (achiote), garlic, plantain, cinnamon, eucalyptus, guava, mango, jacaranda, ginger, lemons and limes, okra, ocote, chamomile, mint, and thyme. In simple language, charts, and illustrations, the training manuals explain how to utilize the various parts of the plant, including the seeds, stalks, leaves, roots, fruit, skin, bark, juice, and essential oils, used to prepare infusions, tinctures, syrups, ointments, unguents, salves, and poultices. The Phytotherapeutic Manual, a basic guide in the teaching materials, includes detailed information on each plant's botanical identification, medicinal uses, proven effects, chemical composition, toxicity, methods of extraction, and bibliographical cross-references citing the scientific source studies. The plants, in their various forms, are used as antiseptics, antacids, expectorants, analgesics, laxatives, diuretics, astringents, emollients, muscle relaxants, and anti-inflammatory, antibacterial, antifungal, antimalarial, and anticonvulsive agents, among others. They are used to treat sore throats, colds, strep throat, tonsillitis, asthma, sinusitis, bronchitis, indigestion, morning sickness, menstrual pain, earaches, influenza, toothaches, insomnia, high blood pressure, diabetes, gall bladder stones, worms, urinary tract infections, conjunctivitis, ringworm, eczema, sunburn, insect bites, pimples, wounds, bruises, and burns. They may not be a cure-all, but medicinal plants are proving their worth in lowering morbidity and mortality rates, restoring faith in the knowledge of ancient precepts about health and disease, and empowering people in the Guatemalan highlands to take control of their well-being and that of their loved ones. -Roberta Okey

"They welcome us and feel comfortable with our medicine," he continues, highlighting a third reason why so many rural dwellers turn to kallawayas for health advice: the kallawayas share the same indigenous roots and traditional world view. Thus, even in rural areas where modern physicians and services are available, many Bolivians are wary of them, perceiving them as too clinical and foreign to their culture.

A Dynamic Mixture

"Western medicine focuses on the individual, giving much less importance to the family, community, and psychological and socioeconomic background as determinants of health," says Dr. Jeannette Aguirre, a national health services consultant in PAHO's La Paz office who works with indigenous groups. "Kallawaya practices are based on a profound knowledge of the patient within his or her natural environment, and on listening to the patient."

Marco Villareal is an agronomist of Aymara descent who lives on the outskirts of La Paz in El Alto. The neighborhood is composed of numerous recent rural migrants, and potato fields sprout up next to thriving micro-businesses. This eclectic mix of the new and the old, the modern and the traditional, spills over into the people's syncretic approach to health care, as well. When Villareal was diagnosed with rheumatism and high blood pressure, "I decided to be treated by a kallawaya, because it is an ancient custom and I've seen the work they do in rural areas. I have faith in them."

But will faith and cultural traditions alone be enough to preserve the kallawayas' ancient healing practices for the future? Fortunately, health professionals and traditional healers in Bolivia are taking steps to integrate the two approaches, with the goal of preserving traditional kallawaya medicine while enhancing the quality and cultural sensitivity of modern medicine.

"Modern medicine has attained a technological level that has proved useful in controlling many diseases," says Aguirre. "However, it does not have many answers for some chronic diseases whose treatment might benefit from a more holistic approach. There are obvious advantages to capitalizing on what both perspectives have to offer us."

"There is a growing emphasis [in the medical profession] on recuperating indigenous medical traditions, especially herbal treatments," adds Linger. "Kallawaya medicine is deeply rooted in indigenous beliefs and customs, which in turn form an integral part of Bolivia's cultural heritage."

PAHO in Bolivia

Since as far back as the 1950s, PAHO has recognized the importance of collecting information on the customs and beliefs of people regarding illness and traditional therapeutic methods. In the 1970s it helped produce a seminal work on kallawaya medical techniques and practices, and in 1994 supported a research project in Cochabamba that studied the methods used by itinerant practitioners of traditional medicine. More recently, PAHO supported the compilation of a two-volume Encyclopedia of Traditional Aymara Medicine by Dr. Gregorio Loza Balsa, who has authored two other books on medicinal plants and Aymara medicine for PAHO.

Through its Health of Indigenous Peoples Initiative in Bolivia and the other countries of the Americas, PAHO works with local and international partners to improve the health and living conditions of this social group. Aware that large segments of the population in countries such as Bolivia, Ecuador, Guatemala, and Peru rely on traditional medicine for primary health care, PAHO works with the academic and scientific community as well as rural health promoters and holistic practitioners to study the potential usefulness of traditional medicine, including evaluation of practices and examination of the safety and efficacy of remedies, and to upgrade the knowledge of traditional and modern health practitioners.

At 390 per 100,000 live births, Bolivia's rate of maternal mortality is the Region's second-highest (Haiti's is first). In a country where 60 percent of all births take place at home and the number of rural home deliveries is high, Linger feels that traditional birth midwives can play an unparalleled role in helping reduce both maternal and child mortality.

"We work with this group, teaching them what to do in situations of complicated deliveries," says Linger. "Although traditional kallawaya medicine helps midwives in their work, they need more training in areas such as prenatal care and hygiene."

Dr. Sandra Land, PAHO's Regional Advisor on Local Health Services and focal point for the Health of Indigenous Peoples Initiative, believes encouraging more indigenous youth to pursue professional careers in health and providing opportunities for indigenous community leaders would help make public health services more culturally appropriate and acceptable to indigenous groups. "Every country has a different cultural reality," says Land, "and community health services must respond to local circumstances and reflect diversity when that is the case."

Preserving Holistic Traditions

Paulino Rasguido, Director of Bolivia's Center for Comprehensive Training and Services for Development (CISED) is devoted to preserving the kallawayas' oral traditions. The small, independent center documents the teachings of kallawayas like Suxo and Barrera, creating a permanent record of their holistic knowledge and practical applications of medicinal plants.

Kallawayas collaborating with CISED relay their wisdom to young residents of Bautista Saavedra through formal lessons and train them to be health promoters. Though economically limited, the Center also trains modern health practitioners because it believes that natural medicine can play an integral role in modern medical practice. "Bolivia has a rich natural plenitude that can greatly compliment modern medicine, especially at the primary health care level," Rasguido says.

The sale of herbs and remedies on a downtown street in La Paz attests to the ubiquitous presence of traditional medicine in Bolivia.

Young people in Bautista Saavedra have a privileged opportunity to grow up learning about medicinal plants and herbs, he explains, but what is really needed is a systematic teaching of their value and unique properties, one that preserves the elderly kallawayas' experiences.

Kallawaya knowledge is passed from father to son by a secret language known only to the kallawayas. Barrera and Suxo are grateful for the skills their fathers taught them but are concerned that today's generations do not regard traditional medicine with the same profound reverence as theirs did. "My sons aren't really interested," shrugs Suxo. Barrera shares Suxo's conviction that kallawaya traditions are in danger of being lost if they are not shared with others.

The Old and the New

Young Barrera sees no quarrel with modern medicine. He says his blending of modern and traditional techniques has made him more useful to the villages that rely on his knowledge. "In delicate cases," he says, "I need to know first aid, because natural medicine cures more slowly."

Unlike Barrera, Suxo, who is older, no longer travels so extensively and instead spends most of his time teaching in Bautista Saavedra. He does, however, makes occasional trips along the old Inca trail to Cuzco, Peru, legendary capital of the former empire, and to visit other small groups interested in acquiring his holistic skills.

"They know very little," says Suxo. "I teach them because I know when I die, my knowledge might not live on. I tell my students I leave them an important legacy, because there is no virtue in the kallawaya tradition becoming lost."