“Love Isn’t There in Your Stomach:” A Moral Economy of Medical Citizenship among Nicaraguan Community Health Workers

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Title:
“Love Isn’t There in Your Stomach:” A Moral Economy of Medical Citizenship among Nicaraguan Community Health Workers
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Medical Anthropology Quarterly (MAQ).
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English
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Nading, Alex M.
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Community health workers
Medical citizenship
Participation
Dengue
Nicaragua

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Abstract:
Drawing on participant–observation in Nicaraguan dengue prevention campaigns and a series of semistructured interviews with Nicaraguan health ministry personnel, this article shows how community health workers (CHWs) balanced two kinds of “medical citizenship.” In some situations, CHWs acted as professional monitors and models of hygienic behavior. At other times, CHWs acted as compassionate advocates for their poor neighbors. In 2008, Nicaragua’s Sandinista government moved to end a long-standing policy of paying CHWs, re-casting them as citizen–volunteers in a “popular struggle” against dengue. Although CHWs approved of the revival of grassroots advocacy, they were hostile to the elimination of compensation. Framing this ambivalence as part of CHWs’ desire to serve as “brokers” between the poor and the state, I suggest that attention to medical citizenship provides insight into the sometimes contradictory ways in which CHWs engage the participatory health policies now taking hold in Latin America and elsewhere.
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(Citation/Reference) This is the authors’ post-print. Please cite the final version of the article, available from the link on the cover page.

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Alex M. Nading Department of Anthropology Franklin and Marshall College "Love Isn't There in Your Stomach:" A Moral Economy of Medical Citizenship among Nicaraguan Community Health Workers _________________________________________________________________ _____________ Drawing on participant observation in Nicaraguan dengue prevention campaigns and a series of semistructured interviews with Nicaraguan health ministry personnel, this article shows how community health workers (CHWs) balanced two kinds of "m edical citizenship." In some situations, CHWs acted as professional monitors and models of hygienic behavior. At other times, CHWs acted as compassionate advocates for their poor neighbors. In 2008, Nicaragua's Sandinista government moved to end a long sta nding policy of paying CHWs, re casting them as citizen volunteers in a "popular struggle" against dengue. Although CHWs approved of the revival of grassroots advocacy, they were hostile to the elimination of compensation. Framing this ambivalence as part of CHWs' desire to serve as "brokers" between the poor and the state, I suggest that attention to medical citizenship provides insight into the sometimes contradictory ways in which CHWs engage the participatory health policies now taking hold in Latin Ame rica and elsewhere. [c ommunity health workers, medical citizenship, participation, dengue, Nicaragua ] ______________________________________________________________________________ The position of . "brokers" is an "exposed" one, since, Janus like, th ey face in two directions at once. They must serve some of the interests of groups operating on both the community and the national level, and they must cope with the conflicts raised by the collision of these interests. They cannot settle them, since by d oing so they would abolish their own usefulness to others. Eric Wolf 1956, "Aspects of Group Relations in a Complex Society" In November 2007, after a spike in dengue fever cases, the Nicaraguan m inisterio de s alud ( m inistry of h ealth ; henceforth MINSA ) initiated an emergency house to house prevention campaign. On a Saturday morning at a schoolhouse in Ciudad Sandino, a low income suburb north of Managua, a group of doctors and nurses joined brigadistas ( community health workers) and volunteers from the Councils of Citizen Power (CPC), a group affiliated with the newly elected government of Daniel Ortega and the Frente Sandinista de Liberaci—n Nacional (FSLN). The day's mission was to eliminate the breeding sites of Aedes aegypti the mosquito that trans mits dengue. Ae. aegypti lays its eggs exclusively in household water supplies such as barrels, buckets, and bowls; it takes refuge in weeds and piles of garbage; a nd it feeds exclusively on humans The personnel assembled that day were to exhort the resid ents of the barrio to take out garbage, to empty water containers, and to be vigilant both for mosquitoes and for individuals with symptoms of dengue: severe h ead and muscle aches, eye pain and nausea Th e procedure was familiar to the brigadistas who re ceived part time pay from MINSA to lead mosquito control campaigns five times each year. This particular campaign was unusual, however because it was among the first since Ortega's election to place CPC volunteers alongside paid brigadistas

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Ortega regai ned the p residency in 2006, ending 16 years in oppos ition. One of his f irst policy maneuvers was to re cast public health campaigns as luchas populares (popular struggles ). Voluntarism was central to lucha s popular es which were common in the days of the N icaraguan Revolution (1979 90) J ust a few weeks after the November 2007 dengue outbreak MINSA began advertising its intention to replace pai d b rigadistas with CPC volunteers in all luchas populares including not only dengue work but also vaccination, AI DS awareness, and nutritional education. In a June 2008 training session, the d irector of Ciudad Sandino's h ealth c enter told brigadistas that although their stipends would be terminated, if they agreed to affiliate with the CPC and act as volunteers, they would be his first choices to lead future dengue prevention efforts. Between 2007 and 2009, I worked as a participant observer in Nicaraguan dengue prevention campaigns and conducted a series of semistructured interviews with brigadistas like Morena Sanc hez who questioned the expectation that she would take to the streets voluntarily: The government wants the people to be conscientious [ tomar consciencia ] to help, to work, for the love of the party, and it's not like that . love doesn't give anyone anything to eat. Love isn't there in your stomach. The brigadistas with whom I had contact uniformly opposed the volunteer policy, and by early 2009, MINSA abandoned the proposition. Still, brigadistas remained ambivalent about receiving pay for communit y health work Pay signified brigadistas membership in a professional health service but brigadistas dependence on daily stipends (roughly U S $1.50 per day) served as a reminder of a n economic and social vulnerability they shared with their neighbors a v ulnerability that social justice oriented policies based on luchas populares promised to alleviate I began research expecting that, given Nicaragua's his tory of popular mobilization, luchas populares could succeed as a political and a public health strat egy. When Ortega took power, hope for health reform was high. Regressive clinical consultation fees were abolished, and more funding for the m inistry was promised. Morale seemed good among health personnel, but brigadistas remained unsure about how they fi t into the revamped system. Their a mbivalence stemmed from a split understanding of community health work The brigadista had to "see" health with two sets of eyes: both "like a state," with bureaucratic and technical rigidity and like a concerned neighbo r, with compassionate flexibility (Scott 1998) A nthropologists have recently turned their attent ion to the ways in which health has become a locus for the arbitration of the rights and responsibilities of individuals against those of the state. I n this ar ticle, I use the term "medical citizenship" to refer to political ly charged negotiations over "who is excluded or sacrificed" when health "resources are . restricted" ( Nichter 2008:183). Recent discussions of medical citizenship have shown how ideas ab out political belonging have begun to converge with ideas about the biomedical condition of bodies. The concept has guided studies of activists seeking equitable ways to distribute AI DS therapies to the poor (Biehl 2004 ; Nguyen 2010 ); of how claims to bodi ly suffering confer rights to "social and economic inclusion" (Petryna 2002 : 5 ; Fassin 2009 ); and of the ways in which concerns about biological vulnerability mark a space of overlap between humanitarianism and im migration policy in Israel, France, and the United States ( Willen 2011 ; Fassin 200 5 ; Horton 2004 ). Th e literature on medical citizenship has left public health campaigns largely unexamined even though hygienic projects including insect control measures, have long been arenas for the moral governan ce of citizens (Horton and Barker 2009) In public health campaigns, questions of inclusion and exclusion revolve less around the recognition of healthy or unhealthy bodies than on the production of healthy or unhealthy spaces.

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In what follows m y aim is to bring ideas about medical citizenship into dialogue with empirical concerns about how community health workers (CHWs) conceive of their practice. D raw ing on 19 months of participant observation in dengue campaigns and a series of semistructured intervi ews with CHWs and Nicaraguan h ealth m inistry personnel, I des c ribe how brigadistas both residents of Ciudad Sandino and part time employees of MINSA act ed as arbitrators between the urban poor and the state. Building on Wolf's classic descrip tion of the Janus faced "broker, I argue that CHWs operationalize two contradictory forms of medical citizenship (Wolf 1956 : 1076). In the first form, citizenship entails individual responsibilities, often of a hygienic nature. CHWs, as representatives of the state, m onitor and model these responsibilities In the second form citizenship entails the enumeration of health needs, to which governments must respond. Here the CHW acts as a good neighbor: a liaison between the poor and the state The Janus image, with its connotations of split loyalty and even deceptive, "two faced" behavior is thus an apt one for describing the place of brigadistas in dengue control encounters Brigadistas quite literally police d the border s between public and private space collective an d individual responsibilit y bureaucratic management and compassionate concern. After sections on methods and historical context, the ethnographic examples in the second half of the article show how brigadistas as dual medical citizens, negotiated an ob ligation to measure and model hygienic responsibility against a duty to help state authorities understand the health concerns of their neighbors I n a concluding discussion, I suggest that, seen as brokers, CHWs might be empowered to act interchangeably as professional representatives of medical authority and as advocates for the poor com munities from which they come. Although CHWs looked favorably on the Sandinistas' revival of community action, they were hostile to the cancellation of pay. Framing this am bivalence as part of CHWs' desire to serve as "brokers" between the poor and the state I propose that qualitative assessment of CHWs capacity to act as dual medical citizens can provide useful insight about the contradictory ways in which actors engage t he participatory turn in public health policy now taking hold in Latin America and elsewhere Such "moral economic" brokerage has been noted in previous studies of how physicians behave as medical citizens (Wendland 2010 ; Andaya 2009 ) but the medical citi zenship of CHWs remains largely unexamined Nongovernmental organizations have demonstrated the effectiveness of CHWs as knowledge brokers in a variety of contexts, from delivery of tuberculosis treatments in Peru to administration of HIV therapy in Haiti (Farmer 2005 ; Standing and Chowdhury 2008 ). In the public health literature more broadly, however, best practice s for the engagement of CHWs specifically the question of whether states should pay them or enlist them as volunteers continues to be a point of debate (see, e.g., Glenton et al. 2010; Maes et al 2010 ; Standing and Chowdhury 2008 ). In both paid and volunteer CHW models, community health is frequently broken up into discrete problems (e.g. maternal nutrition, dengue, and tuberculosis). Solving suc h problems entails measuring and minimizing risk and promoting specific kinds of behaviors. If community health work concerns itself only with such metrics, the answer to the pay question is a rather simple, "utilitarian" one (Morgan 2001 : 228). The model t hat reduces risk and raises responsibility most efficiently should win out. Most dengue control programs have been evaluated from this utilitarian perspective. For example, i n a 2007 metastudy of "community based" dengue prevention programs, Heintze et al suggested that these programs had done a poor job of reducing mosqu ito numbers or dengue case loads (Heintze et al. 2007).

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D ebates about compensation embedded in a utilita rian concern with programmatic outcomes elide a nother component of CHW practice. Although t he communities that CHWs serve are often presumed to be homogenous in low income urban Latin America geographic proximity does not necessarily produce social cohesion (Wayland and Crowder 2002 : 240 ). Though CHWs have figured in health delivery schemes in Latin America since the 1970s during the past decade, leftist regimes have reformed public services in line with a rhetoric of patrioti sm and community building ( see Rigirozzi 2010) As I show in the "H istorical C ontext section of this articl e the debate over pay in Nicaragua was embedded in a long standing n ational conversation about the capacity of brigadistas to forge community state solidarity Brigadistas a mbivalence about paid service thus provides a window into the difficulty of effe cting democratic, pro poor transitions in health policy after decades of austerity in Latin America. For the community workers who mediate between state health ministry and community interests, "p articipatory" health care can be both a vehicle for grassroo ts advocacy and a cunning mechanism for devolving responsibility onto citizens themselves. In her study of cholera prevention in a Chile an shantytown, Julia Paley (2001:152 153) shows how a state policy based on auto cuidado ( self care ) which ostensibly pl aced responsibility for prevention onto private individuals also depended on a rhetoric of collective national belonging This combined appeal to individual empowerment and national ist sentiment obscured the specific conditions that made shantytown resid ents more susceptible to cholera than other Chileans. Crucially for Paley, it was local health practitioners who recognized this obfuscation and worked to address it. In a more recent study, Jonathan Maupin (2011) trace s changes in health policy in Guatema la, where a conflict arose between promotore s de salud CHWs wi t h curative biomedical training, and guardianes de salud CHWs whose job was to refer patie nts to biomedical caregivers. In Guatemala, the technical service delivery role and the community liai son role of the CHW were split between guardianes and promotores reducing the ability of either to act as "empowering" figures. Maupin concludes that CHWs must be recognized for their ability "to negotiate . identity and practice in order to provide c omprehensive healthcare (2011 : 52). M y analysis of brigadista experiences also suggests that CHWs must work as bidirectional actors From this standpoint, community health work is not just a set of specific services (e.g. mosquito abatement) remittable wi th cash, but also the distribution of a generalized public good (i.e. access to the health system) remittable with public esteem In the ethnographic examples below I frame the negotiation of these services and public goods as a moral economy of medical citizenship." Physician anthropologist Claire Wendland proposes that the moral economy of medicine has two distinct tiers. At one level, health care workers value quantification and measurement as shared practices that unite them in a scientific communit y (Wendland 2010 : 285) CHWs ( or in Wendland's case Malawian medical students) strive to act as the hands, eyes and ears of a professional ized health ministry In dengue campaigns, brigadistas behaved as model citizens demonstrating hygienic discipline and encour aging their neighbors to do the sam e. At another level, mediating figures like CHWs see themselves as uniquely able to regulate the relationships between "dominant and subordinate" social groups, namely the medical authorities they represent and the marginalized communities from which they co me (Wendland 2010 : 196). In this sense, CHWs are less m odel c itizens than citizen witnesses. Their simultaneous proximity to the health ministry and to its "targets" leads them to question the limits of hygieni c discipline Elise Andaya (2009) makes a similar observation in her study of Cuban doctors, for whom the delivery of universal medical care was idealized as an altruistic "gift" that strengthened social

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solidarity. In a liberalizing Cuban economy marked b y growing inequality however, the practical separation of the socialist "gift" from the remittable service became more difficult (Andaya 2009 : 366, 368) I n Nicaragua, debates among CHWs about their responsibilities as citizens were moral economic in two s enses Brigadistas saw their work not only as monitoring and measuring behavior but also as forging a bridge between the poor and the state ( Cor e i l et al. 1997 : 163 ). B elow, I show how t he convergence of discipline and dedication was phrased in brigadistas parlance by the terms cantidad (quantity ) and calidad ( quality ). Building on these two concepts, I suggest that the work of CHWs entails managing a tension between the bureaucratic gaze of the h ealth m inistry and the contingent re turn gaze of the communit y Context and Methods Ciudad Sandino was founded in 1969, after a series of floods displaced families who lived on the shores of Lake Managua. When a 1972 earthquake destroyed central Managua, thousands more relocated to the area In the 1970s, the sec tor became known for both intense poverty and a strong affiliation with the FSLN (Pichardo 1993; Barreto 2001). By 2007, Ciudad Sandino was an independent municipality complete with a small h ealth c enter. My research base was the h ealth c enter's office of epidemiology. Staff included a full time epidemiologist and vector borne disease specialist, who together recruited brigadistas The epidemiologist was responsible for maintaining data on the incidence of infectious diseases, including dengue, while the en tomologist kept tabs on the whereabouts of Ae. aegypti mosquitoes. I worked as a participant observer in the epidemiology office for five to six hours per week but my household visits with the vector borne disease team, which included 24 brigadistas yiel ded the most data on the CHW's role as dual medical citizen. The brigadistas were all drawn from Ciudad Sandino's population, comprised mainly of poor, underemployed residents. Ninety percent were female. Aside from training in the basics of first aid, non e had advanced biomedical education. Of the 24 with whom I had close contact, five (all female) operated medical casas bases ( base houses ) where neighbors could obtain bandages, analgesics, condoms, oral rehydration salts, and advice on how to navigate th e health system. I participated in six half day training sessions, five four to five week dengue prevention campaigns (roughly six hours per day, five to six days per week) and a doze n weekend long supplementary campaigns. I observed and documented mosqu ito control visits and carried out impromptu interviews with the brigadistas between visits and on lunch breaks Though Ciudad Sandino had a few parks and a plaza, the landscape was for the most part a monoculture of houses. Almost every house sat on a lo t of 10 by 30 meters, and most included between six and nine residents. Inside, houses were typically divided into a single living and dining room and one or two satellite rooms. U sually there was a thin partition, if any, between living sleeping, and coo king areas. In back of most houses was an open air patio where families kept sinks, toilets, and washbasins for clothes and dishes. It was the patios that the brigadistas inspected for evidence of mosquito larvae. It was essential to reach as many houses a s possible, because there was zero distance between lots. Ae. aegypti mosquito es could easily fly from one household to the next. In a typical day, each brigadista visited 30 to 40 homes. Each visit lasted between 10 and 20 minutes. I compile d detailed wr i tten notes on the daily home visits and impromptu interviews. I transcribed and coded notes and recordings in a database us ing k eyword s to identify moments when responsibilities and rights were discussed. Between and after the home visits, I conducted

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sem istructured interviews of one to two hours with 12 of the 24 brigadistas (ten fem ales and two male s ) as well as with the h ealth c enter's epidemiologist, epidemiology nurse, director of vector borne disease control and the five full time mosquito control technicians Interviews were done in Spanish and digitally recorded when permission was granted and circumstances allowed. When unable to record, I made detailed notes immediately afterward. A fter transcription and translation of the recordings I analyzed them to identify when and how questions of quality, quantity and state citizen dynamics were discussed. I was the sole interviewer, transcriber, and translator A ll names herein are pseudonyms Historical Context: Brigadistas and Political Transitions The influence of the brigadistas peaked in the years immediately after the 1979 Nicaraguan Revolution, which was preceded by the 1978 Alma Ata declaration on primary health care After Alma Ata the presence of active CHWs in developing countries became a proxy for the political empowerment of underserved populations (Morgan 2001; Rifkin 1996) In the early Revolutionary period Nicaragua's brigadistas styled themselves as multiplicadores (multipliers). With the aid of international solidarity groups, they banded together to teach their neighbors about health problems and the relationship of these problems to underdevelopment. Their hope was that demands for better care would emanate from the grassroots to t he centers of political power. Early brigadistas w ere involved in health as well as in literacy, public works, and political education. Evidence suggests that their advocacy led to improvements in roads, sewers, gutters, and potable water systems (Barndt 1991 ; Dona hue 1986; Garfield and Williams 1992). B y the middle of the 1980s, however, a debate was underway about the place of community health workers within MINSA A portion of MINSA's leadership called for a de emphasis of grassroots work in favor of biomedical standardization. B y the mid 1980s this f action had successfully moved primary care from the streets where brigadista p ower was strongest, to h ealth c enters staffed and managed by doctors and nurses (Garfield and Williams 1992). Meanwhile, brigadistas were absorbed into the Sandinistas' increas ingly partisan state order via a nationwide community organization, the Committees for the Defense of Sandinismo (CDS). During the first Ortega administration (1985 90), the CDS helped organize campaigns for literacy and health, but it also preserved order during the heat of the contra war by informing on dissidents and reporting mothers who shielded their sons from military conscription. While the tension within MINSA about the relative importance of community workers and biomedical practitioners seemed to have been resolved in favor of biomedicine by the late 1980s, the CDS itself underwent an internal debate about the relative importance of community advocacy and political discipline. As CDS leader Omar Cabezas remarked, T he flies that breed disease are not sectarian" ( Env’o 1989). As the war sputtered to its conclusion many brigadistas and other CDS members were coming to view themselves as political agnostics. After the FSLN's 1990 electoral defeat, a series of center right regimes continued the de mo bilization of grassroots groups. In the early 1990s, b ilateral aid to Nicaragua actually increased but p er capita health spending on health dropped by some 12 percent (Birn et al 2000; Tesler 2 006 : 134). Amid the austerity the brigadistas were, paradoxic ally, pulled more firmly into MINSA. The number of students and younger adults in the ranks increased as former CDS members retired. These new brigadistas became piece laborers, aiding in the distribution of vaccines, oral rehydration salts, and mosquito l arvicides ( Tesler 2006 : 455). Whereas in the early 1980s brigadistas tended to address a wide variety of health issues simultaneously, by the early

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2000s, most health centers, including Ciudad Sandino's, had begun paying them for disease specific interventi ons. Shortcomings in MINSA's willingness to train or equip brigadistas it seemed, were covered up by monetary stipends, on which the brigadistas still overwhelmingly poor, came to depend (Birn et al. 2000). When the FSLN returned to power in January 200 7, it recast MISNA's public health campaigns as luchas populares L eaders drew on a narrow slice of the R evolutionary past, in which party, state, and brigadistas were closely aligned via the CDS. The resurgent FSLN and its new grassroots arm, renamed the Councils of Citizen P ower ( CPC ) saw a potential not just to build a will to healthy behavior among the populace but also to suture community concerns back to those of the party state Though the CHW model was widely adopted in the Americas after Alma Ata the social justice orientation of CHW s began to diminish in the 1990s supplanted by an apolitical, "technical" orientation (Morgan 2001; Rifkin 1996). The CHW's role as advocate as Perez and Martinez (2008 : 13) warn, has been jeopardized by the "instit u tionalization" of her work: its reductio n to data collection and drug provision. When the FSLN revived the luchas populares the professional authority of the brigadistas as representatives of the health m inist r y which was confirmed largely by pay for ser vices, blended with historically informed aspirations to community advocacy In the next three sections I of fer evidence from participant observation and interviews with brigadistas to show how they negotiated their tenuous professional standing with a sm oldering sense of community solidarity Dual Medical Citizenship : Ethnographic Examples Motivations: The Brigadista a s Professional and Good Neighbor Around 2000 Yamileth, a 37 year old brigadista managed to buy a small plot of land with savings from her work selling refurbished shoes. Soon after that, she met an American evangelical pastor and missionary who was visiting a church on her block. Yamileth a devout evangelical protestant, invited the pastor inside her plastic and wood shack and began a friendly relationship with him, explaining how her husband had consistently failed to find steady work and how they struggled to maintain the house and raise four children on the shoe business alone. A few months later the pastor sent Yamileth money to b egin improving her house. Although people in Ciudad Sandino occasionally obtained such "sponsorships" from North American benefactors often through evangelical networks, Yamileth began hearing rumors that people suspected her of selling drugs or sex to ob tain her new house Though she was by no means wealthy ( in 2008 she and her husband together earned between U S $ 2.5 0 and U S $ 3.5 0 per day ), she responded to these rumors by becoming more active within the barrio She began working as a pre school teacher, h elping organize food and aid for families with deceased relatives, soliciting MINSA to open her house as a casa base and becoming a brigadista Yamileth 's motivation was partly economic (she depended on the stipend), but largely moral. "If one is blessed she explained, one must bless others." She saw her brigadista work as a duty conferred on her by her relative prosperity but she found it rewarding "I've learned so much from the campaigns she went on "And when I visit the same houses over again, people are g lad to see me. Oh, it's her!' they say!" The esteem Yamileth felt from her neighbors helps explain why she seemed so pained as she told me the story of the time two of her sons contracted dengue. She recalled carrying her children to hospital, waiting in agony for a diagnosis, and

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coming home to watch MINSA technicians treat her home and those of her neighbors with insecticide fogging machines: "How is it possible," the doctors and fumigators asked me, "that you go out abatizando [shorthand for working in dengue campaigns] and there's dengue in your house?" Soon after her children started showing symptoms, she, too, felt sick. As the three of them convalesced, she began to wonder if the y had contracted dengue because her work as a brigadista had brought her into contact with an infected mosquito. Once again, events inside her house caused her to feel embarrassed and ashamed at the glances of neighbors. This time, however, she committed herself to spending more time at home. She decided that if ot her hospital workers the ones with uniforms, for example could take a day off to care for their families, so could she. "What they pay us," she explained, "they don't call a salary. They call it a refrigerio [ lit. refreshment]. So they don't treat us lik e real workers." Nevertheless, in late 2008, when it came to the attention of h ealth c enter leaders that Yamileth had skipped a day of brigadista work to care for her children a son sick with a cold, a daughter who had been beaten up by a boyfriend, and an other son who had been injured a street fight she was fired. Yamileth was fired because she was caught in a paradoxical situation. She was trying to make her own home healthier by being present to care for her family, but in order to do this, she felt obl igated to teach her neighbors how to keep their homes healthy. Sandinista billboards promoted solidarity between the state and the poor, even quoting the "Internationale:" Arriba los pobres del mundo (Arise ye wretched of the earth !), and Ortega routinel y blended the moral economic rhetoric of socialism with Christian messages. In luchas populares the government would act through a network of concerned neighbors the CPC cadres but Yamileth wondered if the CPCs were willing to do the work properly "The B ible also says we should love the poor," she remarked making implicit comparison to the Sandinistas' messages, "but not everyone has this attitude." Like other brigadistas Yamileth perceived that the government's new CPC recruits lacked the esteem tha t she and other experienced brigadistas had cultivated In part, this was because of suspicion that th eir political allegiances were more important than their medical qualifications. Yamileth elaborated : "T hey get brigadistas who . are working por and ar paseando [ just for fun]. And the good brigadistas that know how to do the job . they've excluded us . . They don't value the work we do . . We know how to work with dedication! Yamileth saw her firing as a violation of a moral contract. Her invocation of dedication was rooted in an understanding of the dual nature of brigadista practice. In return for her work Yamileth wanted to be valued not just with money ( i.e in quantitative terms) but with an acknowledgement of her commitment to her family and her neighbors ( i.e., in qualitative terms) As state investments in health services eroded in the 1990s and 2000s, and as public and private resource became more unevenly distributed, brigadistas found it difficult to win the esteem of either t he government or their neighbors. Community trust in the brigadistas was not a given, and for the CPCs, such trust was perhaps even harder to build Despite this difficulty Yamileth's was the only case of "firing" I documented Over the five campaigns I observed, t he pursuit of higher paying work particularly in maquiladoras in free trade zones was the main reason brigadistas resigned Six of 24 missed at least one campaign for this reason between 2008 and mid 2009. Two others retired for health or child care needs. O f these eight, three returned for subsequent campaigns. Though they opposed the elimination of monetary stipends brigadistas were careful to clarify their motivations. As a

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Xochitl a 28 year old brigadista who missed one campaign due to a pr egnancy explained I have done what I can . for my pay . for what they give us, and also because . you know, you can save a life . . Although it seems impossible . but lives get saved Like Yamileth Xochitl had grown up watching Nic aragua's public health services deteriorate. She found value in the work was not only in its confirmation of her place in a professional community but also in its affirmation of her legitimacy as someone who "saved lives" beset with struggle s similar to he r own. Xochitl framed her economic needs "my pay," "what they give us" as coeval with the vital needs of the people she hoped to "save." Money was clearly a motivating factor in retention, but so was the potential to provide a meaningful service. As they s truggled to justify the continuation of daily stipends, brigadista negotiated an identity split between professional discipline, glossed in the term cantidad (quantity ) and neighborly empathy, glossed in the term calidad (quality ). Quantity and the Burea ucratic Gaze : Medical Citizenship as Hygienic Discipline In late June 2008, two men posing as brigadistas forced their way into a home in central Managua and robbed its occupants. The story appeared on Managua's widely viewed national newscasts and prompt ed Ciudad Sandino's brigadistas to complain to Don Francisco, their field coordinator, that they should be given clearer ways to identify themselves: uniforms, hats, shirts, or badges. Don Francisco and the five full time entomological technicians who assi sted him wore sky blue uniforms, from which their collective nickname, los celestes was derived. While some brigadistas had MINSA caps or t shirts, most distinguished themselves with little more than a flimsily laminated national identification card. The brigadistas made up for the lack of uniforms through other kinds of discipline. Each morning, Don Francisco insisted that they line up and "pass inspection." He and the other celestes would review each brigadista 's equipment clipboard, informational materi als, pencils, markers, a granulated organophosphate larvicide known as abate as well as attire: clean pants, shirts, and some kind of hat. (The brigadistas noted that the robbers were reportedly wearing t shirts and shorts. Perhaps, they surmised, the vict ims should have known better than to let them in, but perhaps brigadistas in that particular barrio weren't so disciplined.) The centerpiece of the brigadista tool kit was a worksheet with boxes for each type of potential foco ( mosquito breeding site). Foc os i ncluded tires, buckets, barrels, and s inks In each visit, brigadistas had to record the kind and number of focos found ; apply abate to each foco ; note the quantity on the worksheet; give the homeowner a short explanation of how mosquitoes transmitted dengue; and, again, mark the worksheet. During the revista brigadistas would recite the inspection technique: "From right to left, inspect all the flower pots and all the barrels, counting how many grams of abate you use, and don't forget to look up, on t he roof, on the shelves, because they also breed there!" Signs of mosquitoes or their larvae were prompts to initiate a charla or briefing, the conclusion of which was that homeowners could not simply wait for the next brigadista to arrive. Each household er had to make the inspection technique her own. Don Francisco, the celestes a nd their superiors from the regional MINSA headquarters would spot check the numbers on the worksheets by re inspecting houses. The need to complete the requisite daily number o f visits (30 40) without under or overdistributing abate was encapsulated in brigadista discourse by the term cantidad At the same 2008 training session in which the government's plan to eliminate pay for service was announced, experienced brigadistas were asked to demonstrate an efficient

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inspection They put together a sociodrama ( short play ) acting out a typical encounter with a householder. In it, an imaginary brigadista (B) came to an imaginary door and asked for permission to enter. But the house holder (H) was resistant: H: We're all clean here B: Oh, I'm sure, Do–a b ut we have to visit all the houses and inspect them. It's my job, you understand. They supervise us. [ The actress mimed looking up and down a street. ] H: Yes, but we're all clean here B ut maybe you can just pass me a little bit of abate. For the ants, amor. You understand. We've got no mosquitoes here B: I'm sorry, I can't do that, Do–a It's prohibited. The bosses check up on us. And you see, there's lots of cases of dengue in the barrio right now . . We all have to be responsible. H: All I know is that here it's all clean And you know the mosquitoes and the flies? They come from the mud puddles in the street, and from the neighbor over there. You should see the mess she's got in her house . . From there, there's where all the sickness comes from, not here. Now, can you give me a little abate? The sociodrama illustrated a delicate disciplinary dance. T he brigadista drew on the trope of surveillance as she attempted to evade the homeowner's request that she "give her a little abate ." Eventually, the brigadista got permission to apply the abate herself leaving the imaginary householder impressed with the speedy and painless process. Brigadistas "quantitative" sense of their jobs and t heir job security began with the rigid bureaucratic management of abate and the other aspects of home visits In a July 2008 meeting Don Felipe told brigadistas that his superiors at MINSA were unhappy with the group's progress. Just halfw ay through a five week campaign, they had expended all of the abate allotted to them "We can tell when your notes are inaccurat e ," he warned. "I f you just give the abate away they won't have any reason to let you into the house Abate is a good tool, but it is only a tool." Frugal use of abate was a sign of quality surveillance and judicious engagement. Householders had to be taught to police themselves and not, as a social worker in an NGO dedicated to dengue prevention told me, "to fetishize the chemica l." Given dengue's unique ecology (it is spread by a mosquito that breeds and feeds exclusively in human dwellings), experts agree that house by house mosquito abatement must play a part in any prevention strategy but overuse of chemicals or misreporting of coverage remains a concern (Perez et al. 2007; Suarez et al 2005). The sociodrama with its depiction of abate 's proper (economical undifferentiated ) application illustrated the brigadistas technique fo r "seeing the dengue problem as trained health professionals, and for teaching their neighbors to do the same (Scott 1998 ; Wendland 2010 ). An ability to make home visit s the initiation of disciplined practice and not the occasion for a handout distinguished the brigadistas Door to door campaigning was commonplace. Salespeople, bill collectors, evangelicals, social scientists, and politic ians all used similar strategies The brigadistas who continued to oppose the replacement of paid work under the banner of MINSA with volunteer work under the guise of the CPC, used the sociodrama to show that a good CHW well trained, well mannered was distinct from these other figure s precisely because a good CHW, acted in a uniform manner. The brigadista in other words, was a professional citizen: a model producer of healthy space.

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Quality and t he Return Gaze : Medical Citizenship as Empathy and Advocacy Don Francisco and the brigadistas talked frequently about cantidad es : number of foco s found, number of houses visited, and grams of abate dispensed but they als o re cognized that una visita de calida d ( a "quality" visit ) required the establishment of trust between brigadista and householder The protocol and the standardized forms homogenized the brigadistas target audience. In the hands of professionals, these s urveillance tools could address and describe any Nicaraguan citizen, in any neighborhood. While the sociodrama demonstrated the importance of modeling responsibility thro ugh surveillance brigadistas' sympathy with the day to day struggles of householders led to a parallel set of practices, in which a bureaucratic gaze w as less important than a compassionate one In a "quality" visit the brigadista acted as a liaison between the poor householder and the government As Wayland and Crowder (2002) found in a co m parative study of CHW programs in Bolivia and Brazil, empathy bet ween CHWs and those they visit even when they a re neighbors, is far from given. One of the shortcomings of MINSA's rigid surveillance strategy was that it bred suspicion. A s in the sociodr ama householders routinely tried to evade surveillance by blaming mosquito infestations on "dirty neighbors. Though MINSA supervisors I interviewed understood that such scapegoating could make the intervention socially divisive both time and abate were in short supply. MINSA was keen to w in what it began calling a "war" against mosquitoes (Aguilera 2009). Don Francisco and his team had to show results: houses visited, foc os eliminated and abate used wisely As the dengue season grew more intense, neighb orly calidad was subsumed to bureaucratic cantidad As supplies of abate ran short the celestes began telling the brigadistas "Don't waste your time on clean houses F ocus on the dirty ones." In line with a MINSA crackdown on garbage scavenging and trad ing, which itself stemmed from a call by epidemiologists for targeted attention to "ri sky behaviors," t he celestes s uggested that the houses of the garbage scavengers who lived near the city's dump houses full of cans and bottles that c ould easily collect rainwater w ould contain a large quantity of focos. I asked brigadistas about this directive and what it implied about the relationship between quantity and quality Melisa a 2 7 year old brigadista had been recruited to community work by her mother in la w, who was an active CDS member, operated a casa base and had led hygiene drives in Ciudad Sandino f ro m the early 1970s through the late 1990s Even in the days before the Revolution when health services were nonexistent in the slums the community leade rs who would later comprise Ciudad Sandino's first corps of brigadistas work ed to improve hygiene through collective action organizing teams to install sewers, roads, and water systems (Barreto 2001; Pichardo 1993) When the subject of garbage scavengers arose, Melisa answered by recalling those days : I say sometimes it's us, the owners of the houses, that are responsible for propagating sicknesses . and somet imes I've seen also for example . the latrines [scavengers tended to have pit latrines r ather than flushing toilets] . There . you'll find mosquitoes . Maybe . if we got rid of those puddles of water Melisa wondered whether the scavengers like the grassroots activists of her mother in law's generation, should show more res ponsibility for the state of their homes, b ut as the mother of two young children whose brigadista work was supplemented by informal work as a laundress,

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seamstress, and ambulatory food vendor, she also understood the struggles they faced. She continued : B ut sometimes . we . well, sometimes there's not enough time or money . there are lots of people who don't . w ho don't have enough to buy pipes, who don't have enough to buy a toilet. How much does a new toilet cost? Around a thousand, two thousand [ c—rdobas U S $25 to $50]? . Poor people aren't going to go out and buy no way! And so this is always going to occur, always, these cases of dengue! Melisa tacked from personal responsibility to structural limitations. Just as she started dow n this more compassionate line of explanation, however, she tacked again: But look . sometimes I think it's not necessary for one to live so poor and miserable. Because sometimes it depends on us . . It's part of our self esteem, part of ourselves . . Being poor doesn't mean living like a pig. Although she took seriously her duty to educate her neighbors about dengue, Melisa knew that livelihood strategies such as garbage scavenging could place economic survival in conflict with prevention. Whi le garbage might be a foco in the language of the worksheets, for many households, garbage was a key economic resource. And while a specific concern for the whereabouts of mosquitoes might lead to a temporary decrease in dengue incidence, a generalized con cern for food and shelter appeared to stand in conflict with that goal. The directive to target scavengers raised questions about brigadistas' ability to establish empathy with their neighbors, and about which neighbors were deserving of such empathy Brig adistas regularly confronted householders who wanted to blame neighbors for the dengue problem, but they also f reque ntl y faced the expectation that they would relay questions and complaints even about health problems other than dengue back to MINSA In S eptember 2008, Morena was interrupted in the midst of a dengue inspection "The problem with the mosquitoes, the bugs, whatever," her host said, "is that ditch!" She pointed behind the house to a storm sewer. "All the sewage from the colonia up the hill [ a middle class housing development] get dumped on us here in the barrio MINSA needs to attend to that sewer!" Morena agreed to inspect the ditch, which was full of foamy liquids and reeking garbage. She jotted down details about the situation and gave the woman the name of the municipal epidemiologist advising her to contact the h ealth c enter. Morena lived i n the household of her in laws and she was under pressure to earn money for the family She was also eager to be out of the house as often as she co uld. Sh e was part of the Sandinista y outh auxiliary in the 1980s, aiding in literacy campaigns and in coffee harvests. She became a brigadista when she moved to Ciudad Sandino, looking as she put it, for "satisfying work. MINSA paid a small wage, and bri gadista work provided time outside the house and gave her a sense of mission. For Morena, calidad meant taking the "extra time" to listen to her neighbors' problems, and to help solve them E ffecting una visita de calidad was the most fulfilling part of th e job Completion of the bureaucratic part of the job demonstrated in the sociodrama was necessary, but not sufficient, for establishing her place as a liaison between her neighbors and the state. Calidad connoted a compassionate engagement that affirmed t he brigadista 's membership in th e moral community of her neighbors (Nading 2012)

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Still, like Yamileth and Melisa, Morena was regular ly in need of extra money. S h e would even sometime s scavenge for aluminum cans during the dengue campaigns fishing them out of gutters and into the bag where she kept her granulated abate Though a pound of cans yielded about 50 U.S. cents in mid 2008, prices fluctuated rapidly, and full time scavengers tended to keep piles of aluminum and other items in their homes awaitin g a spike. Considering this Morena explained: You have to use your powers to convince [scavengers] Sometimes you have to lie and tell them that there is more dengue in the area than there really is. But sometimes you have to tell them that you don't wa nt to rob them of their income by reporting them. You have to negotiate. T o cross the threshold of a house, a brigadista needed the identification card, the worksheet the abate and the rigid routine, but in order to remain inside, she had to demonstrate an understanding of the (perhaps "unhealthy") livelihood strategies of her neighbors It was in the figure of the brigadista not the celeste or the epidemiologist, that the ordered, inward looking gaze of the disciplined citizen was met by the contingent outward gaze of the struggling neighbor For the brigadistas a "quality" visit ensured both that the poor woul d not fall victim to the careless practices of wealthier neighbors and that MINSA would temper rigid dedication to hygiene with flexibility and compassion Discussion : A Moral Economy of Medical Citizenship As I proposed in the introduction, CHWs are "Janus faced" broker s between the poor and the state (Wolf 1956) In the context of scarce resources and inequality, community health work require s a willingness to balance two contradictory forms of medical citizenship one disciplinary and bureaucratic, the other compassionate and flexible. On one hand public health campaigns make legitimate citizenship synonymous with a hygienic discipline that can be measured through careful surveillance. As those responsible for that measurement, brigadistas embraced a professional technical ethic. A dispassionate fidelity to precision became a value in itself: a "quantitative" expression of their worth to the m inistry and the state (Wendland 2010 : 196) Formal daily wages, uniform dress, and comportment were all evidence of this value In community based dengue control projects throughout the world success continues to be measured in what the brigadistas might call "q uantities :" mosquito population s cost ( of wages and chemical or biological agent s) and dengue case loads Although there is no evidence of a correlation between these figures and individuals' willingness to clean water receptacles, rid homes of m osquito habitats, and be vigilant for symptoms of dengue such quant itative measurements have nevertheless become proxies for a kind of hygienic discipline and moral fitness, passed from CHW to householder (Elder and Lloyd 2006; Perez et al. 2007; Suarez e t al 2005 ). In most dengue prevention contexts, surveillance is directed at poor populations, and it is significant that it is most often carried out by CHWs who a re also members of those poor populations. Conscious of a n ational history of grassroots mo bilization brigadistas found themselves making complex negotiations between the value of professional discipline and the value of advocacy A s many of their neighbors' most regular contacts with MINSA, the brigadistas had a unique opportunity to demonstra te compassionate service. In searching for this

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"quality," brigadistas operationaliz ed a second version of medical citizenship. As they struggled to determine the extent to which the poor garbage scavengers were responsible for dengue, brigadistas ask ed th emselves not only about their moral fitness, identifiable in hygienic practices, but also about what Goldade, in a study of Nicaraguan migrant women's systematic exclusion from Costa Rica's nominally "universal" health care system, calls a "worthiness to receive attention ( Goldade 2009 : 487 ; Fassin 2009 : 51, 59 ). For brigadistas preventive action, insofar as it gave marginalized people direct access to the health system, had to be inclusi ve : a solidarity producing "gift" (Andaya 2009) Influenced by a smold ering Sandinista ethos of social justice they felt a duty to create this kind of inclusion For Wolf the power of "broker s peaks when the relationships between "nation" and "community" stand to be recalibrated (1956 : 1076) While the legacy of Sandinista health nationalism remained strong in Nicaragua a lengthy period of austerity had a clear impact on public health practice. The Sandinista regime's luchas populares were designed both to de monstrate its commitment to professional care and to show that it valued empowering public participation. When asked to manifest this dual commitment, the brigadistas embodied the conflict between "seeing like a state" and seeing like a good neighbor (Scott 1998). Brigadistas desired both recognition from MINSA as medic al professionals and recognition from their neighbors as sympathetic advocates It was not always self evident to those neighbors that mosquito abatement was in their best interests just as it was not self evident to the brigadistas that Ortega's revival of voluntarism and community activism would succeed The movement of left leaning governments in Latin America to a more socially just public health based on participatory action masks subtle inequalities like the fortune that distinguished Yamileth fro m her neighbors and tenuous affinities like the muted empathy between brigadistas and scavengers It also elides more stark social divisions like the conflict between colonia and barrio residents that Morena confronted A willing "e xposure" to th ese inequ alities and affinities lies at the heart of the CHW 's political subjectivity calling attention to the importance of routine preventive encounters as moments for observing the intersection of biomedicine, social justice and the making of state subjects T his study invites further qualitative examination of how CHW s address the moral economic contradictions inherent that intersection If their efficacy is view e d only in terms of their ability to produce quantitative health outcomes, CHWs' parallel capacity to act as advocates for a more empowering public health based on a non numerical quality of service may be obscured Note Acknowledgments The research for this article was supported by a Fulbright Hays Doctoral Dissertation Research Award; the Social S cience Research Council; the National Science Foundation (Grant # 0849650); the University of Wisconsin Madison Graduate Student Collaborative; and Franklin and Marshall College. An earlier version of this article was presented on the panel "The Right to t he City in Third Century Latin America: Ethnographic Perspectives" at the 2012 Congress of the Latin American Studies Association. I am grateful to Erika Robb Larkins, Daniel Goldstein and Dennis Rodgers for their helpful advice and comments on that draft This research would not have been possible, however, without the patience and understanding of the staff and volunteers at the Hospital Nilda Patricia Velasco de Zedillo in Ciudad Sandino, Nicaragua. I wish also to express my thanks to the anonymous

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