In Yunguyo, vendors and villagers from around the region convene every Sunday to exchange goods. Because there are few opportunities to obtain items during the week, the market draws thousands of participants, turning a sleepy village into a bustling center for trade. But just as quickly as the market sets up, it comes to an abrupt end. In the late afternoon, traders head back to their homes; this is when the sun starts to fade and the temperatures drop. In the rural Andes, travel by night can be difficult, cold, and dangerous. Vendors face unlit roads and walkways while on alert for thieves who are after unsold goods and profits. At night one is also more apt to be attacked by the kharisiri.
To gain another perspective on this issue, nine pharmacies in Puno were visited, five in Arequipa, and four in Yunguyo. The intention was to see if pharmacists could substantiate the extent to which customers ask for medicine to treat kharisiri attacks, and if so; do pharmacists sell them pills, and what is typically prescribed? While the responses were varied, four pharmacists in Puno and two in Yunguyo indicated that customers do ask for treatment for attacks. Yet the pharmacists reported major variations in the frequency of such treatmenth requests. Some reported this happening several times a day and some once every few months. As such, it is difficult to quantify how often this practice is occurring. However, because the majority of pharmacists said that they are not asked for pills to treat kharisiri attacks (especially those in Arequipa), and because the majority of participants reported ethnomedical treatments, it is felt that ethnomedical treatment is indeed more common. We nonetheless find it important to understand people’s rationale behind the use also of pills to cure such attacks.
On two occasions when Rita was suffering from la gripe, she showed the researcher pills that she bought from a pharmacy across from her vending post. Rita referred to the pharmacist from whom she always buys as her friend. Further conversation revealed that this pharmacist was also a regular customer of Rita’s, buying orange juice from her several times a day. On one particular occasion, the pharmacist bought homemade cookies from Rita, after Rita had given her a sample for free. Another pharmacist working at the same time was also given a free cookie, but did not buy any. During our conversation, Rita made the distinction that this pharmacist was not her friend and also said that she would not buy pills from her.
The process of creating social relationships in the Andes is generally based on acts of reciprocity, both with the natural world and with other people. On a daily basis, such acts involve the exchange, sharing, or offering of food, drink, and coca leaves. To refuse to partake in meals or accept food when offered sends the message that one does not wish to enter into social relations with the given person or group. In Rita’s case, she may have felt socially rejected by the pharmacist who refused to buy her cookies. Her preference for the pharmacist she considers her friend may then be indicative of the influence of social relationships in the rationale of treatment choice. If this is true, then the ability to form reciprocal relationships with nearby pharmacists—who are vendors themselves—may be important to consider when discussing why some people use pills to treat kharisiri attacks. As we discuss in the following sections, this social bond may be lacking in other encounters with biomedicine, such as when seeking treatment from a doctor.
Rita was not the only participant to regard a pharmacist positively. A fruit vendor also talked about the “nice woman” who “always” helped him at the pharmacy. Another participant offered to introduce the researcher to her dentist
i without an appointment just as one may show up at a pharmacy. In contrast, participants (with one exception) did not make reference to a particular biomedical doctor. While this may be due to the many barriers to accessing the facilities where doctors practice, such as time and money constraints, it may also be a result of the one-way economic exchanges with staff in a way that is devoid of reciprocity. For example, people said that in hospitals one must pay to be seen in a waiting room before receiving treatment. Once admitted, it is expected that patients bring gifts for nurses, such as chocolate, or they will not care for you. Pharmacists, on the other hand, do not need to be “bribed.” The price of the pills is agreed upon upfront by the pharmacist and the customer in much the same way a vendor may discuss a price with their customer. An additional dimension to consider is that of the relationship to a regular client. It is common practice that a regular customer of a vendor will get special treatment, often being given a bit extra of what the vendor is selling as a symbol of appreciation for the regular business. By regularly visiting the same pharmacist, vendors themselves may expect or benefit from similar patterns of exchanges, particularly in this context where the pharmaceutical industry is relatively unregulated and prescriptions are often not needed [
38,
51].
Beyond potential benefits of being a regular customer, the informality that often exists within the buying and selling of pills mimics the unregulated selling of goods in and around the Feria, and certainly in most other open markets in the Andes. The vending of goods—the authenticity and legality of which may be questionable—positions pharmacists and vendors in a similar social occupational category, which may allow vendors to identify with pharmacists on a socioeconomic level. As illustrated in Logan’s study, clients who relate to pharmacists tend to prefer pharmacists to doctors. Combined with a mutual negotiation of their relationship through the goods they sell, these dimensions contribute in building relations of trust.
The importance of establishing social relations with health professionals should not be overlooked. Wayland and Crowder have explored peoples’ attitudes towards community health workers in an Andean community in Bolivia [
52]. Growth in the community prevented health workers from being able to make as many visits to communities as normal. Community members’ attitudes revealed that they perceived community health workers as “strangers” who were just like “anyone else on the street.” Resulting evidence showed that their health advice was rejected and unwanted. In contrast, Rita’s friendship with the pharmacist may have increased the degree to which she was willing to discuss her health and be receptive to treatment recommendations. Such an example suggests a degree of trust that must precede relationships with health professionals.
To illustrate this argument further, it is worth discussing more in depth participants’ attitudes towards biomedical doctors. In Laura’s story below, she seeks treatment for her young daughter from both a biomedical doctor and a curandera. While the treatments were for the same illness and occurred in a very close timeframe, she attributed the healing to that of the curandera, not the biomedical doctor. As we argue, the contrast of the social relationships involved in the curandera’s traditional healing and the doctor’s treatment, and the participation in the healing ceremony by Laura’s family, appear to have influenced Laura’s reasoning. This case will also highlight how susto is conceptualized differently than kharisiri attacks, which will be an important factor in how the acceptance of pills for kharisiri treatment is analyzed further.
Susto and Mal de Ojo
When Laura’s two-year-old daughter fell ill with symptoms of vomiting, not sleeping, and crying more than usual, she brought her to the hospital. While she was waiting to see a doctor, she discussed her daughter’s symptoms with a woman in the waiting room. The woman felt Laura’s daughter was suffering from
sustoj and gave her the contact information of a
curandera. Laura proceeded to see the doctor, whom she said “did nothing” except prescribe a liquid medicine. Laura gave her daughter the medicine, which she also said “did nothing.” Indeed, as Finkler argues from her work in Mexico, the perceived failure of a treatment from one system is not uncommon in leading to a diagnosis of a spiritual cause through process of elimination [
53]. Later in the day Laura contacted the
curandera whom she was recommended at the hospital and that night a soul calling ceremony was performed in Laura’s house.
The curandera arrived around nine o’clock and all the family members who lived in the house gathered in the same room. Together they performed rituals with herbs and incense and items that belonged to Laura’s daughter. The use of personal items, such as clothing or in this case a doll, is regarded as important in these treatments so that the lost soul will recognize where to return. The ceremony lasted until two in the morning and Laura said her daughter was healthy again after a few days. Even though Laura also gave the biomedicine to her daughter, she credited her recovery to the soul calling ceremony.
Laura, like many participants, emphasized that soul calling ceremonies are typically held on Tuesdays and Fridays, which are considered the best healing days. If a ceremony is not believed to be effective, it may be repeated on the following healing day, typically up to a total of three times. Therefore, a week can pass before a “round” of treatment can be completed, and thus evaluated for effectiveness. Biomedicine, on the other hand, as mentioned, is expected to work immediately. Laura did indeed give her daughter the medicine prescribed by the doctor but also commented that her daughter was better a few days after the soul calling ceremony. Perhaps because her daughter was not better immediately after taking the biomedicine, she believed the medicine was not responsible for curing her daughter. Since a week can pass before a soul calling treatment can be completed, the several days’ delay of her daughter’s healing may be why Laura emphasized the role of the healing to restoring health over the biomedicine, which is thought to work quickly.
As in the case of Rita and her pharmacist, social relations may also be at play in Laura’s case. The time the
curandera spent with the sick girl may have contributed to the perceived efficacy of her treatment. The
curandera spent five hours with Laura’s daughter, which is likely to be much more time than the child spent with the biomedical doctor in the hospital. This length of time may give the impression that the
curandera “did something” whereas the doctor “did nothing.” The time spent with the child would allow the
curandera to get to know Laura’s daughter in a more holistic sense. Bastien quotes Abraham Maríaca’s statement that “Andeans perceive the doctor without a heart because he charges a lot, treats them like a machine and keeps apart from them. The scientific method brings out these features in the doctor. On the other hand, Andeans love the
curanderos who massage, console and communicate with them” [
39]. Children are believed to be especially vulnerable to soul loss and other folk illnesses since their soul is not yet considered strong. A biomedical doctor may be perceived as not holding these same beliefs and therefore not able to treat a child’s illness in the same holistic way. The fact that the
curandera treated the child at home may also have contributed to the efficacy of the traditional treatment in terms of social relations, as it involved the whole family.
As outlined earlier, Crandon-Malamud suggests that medical treatment can be considered a “primary resource” and through its use, one acquires “secondary” resources. Secondary resources are generally socially or politically motivated. One may choose a treatment to align oneself with one’s community or as a statement of one’s beliefs and values. Participants, largely due to discrimination, costs, and long waiting times, did not generally regard hospitals and biomedical doctors positively. In contrast, many participants told positive stories of traditional healings and even offered to introduce the researcher to curanderos they knew. In terms of resources involved in the treatment, Laura and her family were active participants in the healing process, which may be an important factor in why credit was given to the curandera. Laura depends on her family to run a successful banana stall. Her husband is in charge of acquiring and restocking the bananas she sells every day. Laura’s mother cares for her children six days a week while Laura vends, and one day a week her mother vends so Laura can have a day off. Without the help of her family she would likely have to work many more hours and pay for bananas to be delivered. According to Crandon-Malamud, then, it may be that Laura credited the traditional healing as being effective as a way in which to maintain positive ties with her family that support her economic success. Or in other words, by validating the traditional healing (primary resource), she also validated her family’s time and effort, which would work to promote her economic well-being (secondary resource).
This case also demonstrates how different ideas of temporality may influence understandings of treatment effectiveness. For instance, unlike kharisiri attacks that demand immediate treatment, it seems the urgency for treating susto is less, making slower-working traditional treatments appropriate. Furthermore, because immediate treatment is not required, healing susto can wait until vendors (who mentioned not even being able to prepare traditional teas in the market) are free from work, since healing ceremonies occur late at night. The immediacy of treatment that kharisiri attacks require would not be conducive to work if traditional methods were to be relied on. Laura’s case also shows how important social relations are—not just with the person providing treatment but also with those participating in the treatment.
When participants were asked about treating susto with biomedical pills, the answer was unanimously that they were not effective. Naturalistas in the market who were knowledgeable about healing also said that pills could not cure susto and shared the details of healing ceremonies and the materials needed. Vendors repeated the same advice with little variation. The reaction was the same for mal de ojo (evil eye).
Mal de ojo was nearly always spoken about in reference to children, as children are thought to have weaker souls than adults. It was said that if an ill-meaning adult looked at a (usually particularly good-looking) child too long, the child’s soul could be taken over by the stronger adult’s soul, which was thought to be evil. The child, it was said, would suffer from many of the same symptoms as
susto (not sleeping, irritability, fever). Participants described treatment that was intended to “draw out” the evil soul by passing a fresh, uncracked egg over the child’s body, as eggs are thought to have absorbing qualities [
54]. The egg would then be broken into a glass and examined for any abnormalities. A broken yolk, strange markings, or a somewhat solidified egg would indicate a presence of evil and also that it had been successfully removed from the child [
55].
Like susto, mal de ojo is characterized by a disruption of the soul, which is often thought to be a result of failing to uphold reciprocal relations with Pachamama or those within one’s social circle. The understanding of the soul’s involvement in an illness seems to determine whether an illness is understood as bio or ethnomedical in origin. When the researcher asked Rita if a curandero could treat la gripe, which she would otherwise go to the pharmacy to buy pills to treat, she said while laughing, “no, la gripe no tiene nada que ver con el alma” (no, the flu has nothing to do with the soul). An important distinction of the kharisiri, which we were able to draw from participants’ descriptions, is that the kharisiri attacks—like la gripe—have nothing to do with the soul.
Kharisiris
According to scholars, the
kharisiris appeared in Aymara history around the time the Spanish arrived [
4,
14,
39], and there has since been an understanding of the
kharisiri as being a fat and blood snatching foreigner, or stranger
k. The loss of fat at the hand of foreigners is, according to Bastien, symbolic of social and political inequities, whereby its loss represents further abuse and exploitation [
2]. Other scholars have interpreted the
kharisiri as a personification of violence in the relationship between highland and the capital, and between Peru and the United States [
55], as a response to modernization [
56] and as involving an epistemology of race [
16,
17]. Weismantel explores the
pishtaco as an indigenous expression of racial violence, and underlines how his dreadful deeds depict whiteness and masculinity as powerful and threatening. While the
kharisiri may thus illustrate how whiteness and masculinity is understood from an Andean perspective, Canessa explores how the
kharisiri can also illuminate how “indianness” is understood by Indians. As we will return to, he does so by examining the cultural meanings of fat.
Kharisiris are thought to be for instance Catholic priests, politicians, engineers, or biomedical doctors. These positions are either associated with knowledge that originated abroad, or access to power and resources that have worked to exploit people in the Andes. Indeed, several participants stated their belief that the bodily substances the
kharisiri takes are often sold to foreign countries (the United States and Europe were both mentioned) for use in manufacturing that results in “big profit.” Participants often remarked that the extracted fat was exported to other countries where it is used to make consumer goods such as soap and candles, or even used as a lubricant for machines.
This perception that the foreign market profits from fat is referenced by many researchers in the Andes. Crandon-Malamud too writes about how fat was used to create fancy soap to export and to sell to tourists. She also mentions that North Americans used the extracted fat to power their electricity [
4]. Weismantel describes an artistic display set in the 1960’s by an artist in Ayacucho whereby human fat is used to grease engines of airplanes and “modern” machinery [
16]. More recently, in the 1980’s, it was rumored that fat was used by government officials to pay off Peru’s national debt [
57]. According to Crandon-Malamud,
kharisiris have later been associated with the use of fat for the production of cosmetics and medicines at factories or pharmacies, and it was believed that “the materials to extract it [fat] could be bought clandestinely in pharmacies in La Paz” [
4]. This understanding of fat and exploitation is essential to our arguments surrounding the use of pills as treatment.
In
Fear and Loathing on the Kharisiri Trail: Alterity and Identity in the Andes, Canessa notes: “Other illnesses respond to treatment through divination and offerings to the earth spirits, but
kharisiri attacks are outside the relationship people have with the tellurian spirits and therefore the spirits cannot be invoked to cure the victim” [
17]. The two cures Canessa observed in his research were 1) to kill the
kharisiri, or 2) to buy “back” what was taken, generally fat that his participants said could be found in pharmacies. Canessa however makes no mention of pills.
The connection Canessa encountered between fat and pharmacies is perhaps not as peculiar as it may at first appear, since people seemed to make a connection between pharmacies, foreign countries, and exploitation. As noted by Crandon-Malamud, there is also a belief that biomedical pills are made from human fat, stolen by
kharisiris. The participants in our study often associated pills with other countries and often asked the researcher to mail vitamins to them when she retuned to the United States. Participants stressed that pills manufactured abroad (the United States and Europe were mentioned again) were of better quality because education, science, and technology are more “advanced” in these foreign countries. Additionally, it was understood among participants that several of the big chain pharmacies in Peru are owned by enterprises in neighboring South American countries
l. The sentiment that foreigners exploit the people and land of Peru was not uncommon. Informants sometimes discussed with the researcher how other countries, like Chile, take Peru’s rich natural resources (coal and oil, for example) without giving Peru anything in return. This, informants explained, is a reason why Peru remains economically poor. Since the
kharisiri is perceived as a foreign and exploitative figure, it is perhaps significant that some people seek pills from an industry that embodies these same characteristics. Drawing on Foucault’s notion of biopower, Miles for instance notes that “because medicines are meant to heal, those who control their production, and distribution garner a measure of social power…pharmaceuticals, in particular, carry powerful associations with science and technology, and consequently, those who control their distribution are symbolically associated with the power of advanced technology” [
41].
Furthermore, as explained previously, participants believe pills as fast working but also dangerous because of their “powerful” properties. These potent pills may be perceived to be effective in combating an illness that is caused by powerful oppressors—such as foreigners or those who hold political power—who have access to fat-removing technology and perhaps also connections to sell fat for profit abroad [
4]. Keeping in mind that participants perceived healing methods to be quite literal interpretations based on the source of illness (appeasing
Pachamama to restore reciprocity, calling the soul back, or drawing out the evil that entered the body in the case of
mal de ojo), swallowing a pill that represents an industry steeped in foreignness may embody curative elements for
kharasiri attacks. On the one hand this suggests a dependency on the pharmaceutical industry among people who may be perceived as being exploited by it, but on the other hand, pills may also offer a cheaper alternative to traditional cures such as buying fat, which is particularly expensive, and as Canessa notes, is a “double exploitation” [
17].
Fat is associated with life force, and is seen to be something of a protective factor against the hard physical labor and rapidly changing air temperatures that characterize life in the Andes, which are conditions that vendors are particularly exposed to. When the researcher asked participants how they stay healthy enough to work, they nearly always replied, “I eat a lot.” Canessa points out that kharisiris are thought not to attack children or the elderly but only middle-aged adults who are “most clearly engaged in production and reproduction.” Thus he makes the point that when those involved in economic activities are attacked, they—and their families who rely on them—are more likely to remain oppressed due to reduced economic productivity caused by illness or death. Seeking pills for treatment of a kharisiri attack may be an attractive alternative for vendors because they do not represent a significant cost and also because a pill’s effectiveness is expected to be felt immediately, allowing vendors to continue to work and be economically productive.
The economic underpinnings of the
kharisiri are perhaps even more clearly illustrated when seen in the perspective of a broader historical context. As Crandon-Malamud documents, the ways in which the
kharisiri is described tend to change based on the given sociopolitical climate. Based on research in a small Bolivian village, Crandon-Malamud writes that up until the 1950s the
kharisiri was “universally the image of a dead Franciscan monk” who gave victims’ fat to a bishop to make holy oil [
4]. In the following decades the
kharisiri was associated with North Americans, after the community had contact with foreign aid programs that were interpreted “as an attempt by the United States to practice genocide for imperialist gain.” In the late 1970s the
kharisiri was associated with the Bolivian elite and with “any
mestizo who participated in the trade of human kidney fat.” Crandon-Malamud’s point is that the
kharisiri’s identity changes according to who is perceived as the oppressor, and furthermore stresses that society’s social structure may be linked to one’s understanding of health. She goes on to mention that in the late 1970s, there was a period of reform in the community she studied when a health clinic was built and distribution of land became more equitable. At the same time, it became possible to cure a
kharisiri attack, which previously was perceived as deadly. It may be that as the understanding of the
kharisiri evolves so too do the ideas of how to cure its victims.
Furthermore, the methods and tools
kharisiris are thought to use for removing bodily substances are also changing as technology progresses. Fernández Juárez writes that the
kharisiri used to be perceived as “cutting” victims with their own knife [
14]. Now, he says, modern tools are used in extraction, such as cameras, tape recorders, and syringes. Participants in this study almost always mentioned syringes or needles. José even mentioned the use of lasers, which he explained could be used from afar. The evolving nature of the
kharisiri in the context of an ever-changing society may perhaps contribute to the variety of treatments that have been noted throughout history—and why more may continue to be added. Historically, remedies for treating a
kharisiri attack included several traditional treatments like eating fat, drinking blood, wrapping one’s stomach with the hide of a black sheep, and drinking various homemade brews. Among participants there was no single cure that was unanimously recommended. In contrast, participants mentioned only one treatment for
susto and
mal de ojo, which are both connected to the soul and/or social relations and are conditions that have been deeply embedded in Andean culture. The
kharisiri, on the other hand, is a relatively new figure, appearing in history around the time of the Spanish arrival.
Another reason why pills may be accepted as a form of treatment is that the soul and social reciprocity do not seem to play a role in how the illness is understood. As discussed, kharisiris are associated with strangers, implying a lack of social reciprocity leading up to the illness and therefore helping to explain the lack of acts of reciprocity involved in curing the illness. Participants reported that the kharisiri “can be anyone”, and thus attacks do not seem to have roots in social relations. Therefore treating an attack does not appear to have any direct outcomes other than bettering one’s health. The lack of social involvement in the origins of the attack may make the use of biomedical pills—which are less personal than all-night healing ceremonies—more likely to be perceived as an appropriate treatment. This is further evidenced by the many cures for kharisiri attacks participants listed, which all involved obtaining various substances and usually ingesting them to “replace” what was lost. There seemed to be little to no emphasis on relying on family members or friends to obtain the healing substances. The emphasis was instead on ingesting the substances rather than on the process of healing as we saw with the all-night soul calling ceremony, and the method for treating mal de ojo. Additionally, in cases when a soul was returned to the body, participants said they “just felt it.” A soul however, cannot be seen in the same physical sense that fat and blood can be. Therefore, ingesting a pill that can be seen and felt may be perceived as a way to “replace” other physical elements taken from the body. Indeed, considering the previously mentioned association between biomedical pills and human fat, the use of pills to cure kharisiri attacks may be a result of the view that pills contain similar substances to that of fat, only in another form.
It is important not to associate the acceptance of pills with the acceptance of all biomedicine to cure kharisiri attacks. Referring to the kharisiri, participants commonly said “los medicos no creen” (the doctors don’t believe), and if you go to the hospital to be treated for an attack, the doctors will give you an injection and you will die almost immediately. Why is it that injections are perceived to kill but pills are perceived to heal? There are likely to be several explanations to consider. It may be that people believe injecting the body with foreign substances (especially liquid injections) may throw off the “balance” of body fluids necessary for health that is understood under Andean humoral health beliefs. In contrast to the sentiment that doctors “don’t believe”, the seeking of pills may also be explained in part due to pharmacist’s own belief in, or validation of, kharisiri attacks.
Juanita, who works as a nurse during the week and a pharmacist on the weekends in Yunguyo, said that on Saturdays and Sundays “harta gente” (many people) come to ask her for pills to treat kharisiri attacks. She stressed that her husband—a medical doctor—thinks that people are ignorant to believe in the kharisiri “myth.” Juanita said that after fifteen years of working at the pharmacy, she now “believes in the kharisiri for her client’s sake.” Based on symptoms, Juanita said she typically prescribes these customers several rounds (the number of which depending on what her clients can afford at that point in time) of three different pills to be taken three times daily with meals. She remarked that instructions to take pills with meals helps the clients, the majority of who are vendors, remember to take the pills at regular intervals because she knows that they place an emphasis on eating regularly but are not always aware of the time. It is difficult to say if customers come to Juanita because they have heard about her treatment through others, or if they arrive by chance. Regardless, it appears that by listening to her clients without exhibiting judgment, she fosters an environment in which clients feel comfortable to express their health concerns, as they understand them. While on the one hand this process personalizes the relative impersonal nature of a kharisiri attack, the treatment process at the pharmacy still lacks the physical touch and time investment that characterizes the work of traditional healers. In her interactions with clients, she nonetheless validated their beliefs in a way that made clients trust that she knew what pills could treat their illness.
The lack of physical contact in pharmacist interactions may also be an advantage because the situation does not appear to give pharmacists the ability to take any more substances from an already weakened body. Fernández Juárez writes that doctors are commonly viewed as “allies” of the
kharisiri who take fat from patients to profit from [
14]. According to Bastien, “Bolivian doctors are skilled surgeons and so are referred to as “
kharisiris” (cutters) by many rural Andeans.” [
2]. In a hospital, where injections are given, one would be surrounded by those with the know-how to extract fat (doctors), who may be perceived as the source of harm in the first place. If a
kharisiri victim believes this to be so, then the doctor may have motivation to kill the patient to make a bigger offering to the devil, and thus benefit from a larger payoff. With this mindset, seeking treatment in a hospital seems counterintuitive. Drawing from participants’ positive and reciprocal exchanges with pharmacists, it may be that a pharmacist’s ability to relate to clients and their beliefs increases trust, and therefore effectiveness, of biomedical pills over other biomedical options.