Health Care in Bolivia

Primary Care Clinic
As I get off the bus a few minutes before eight, I can see a line of forty to fifty people waiting in the rain outside of the clinic. Most are women, some clutching their pregnant bellies, others nursing a small infant, some doing both. I sneak past them to put my backpack in a staff locker at the back of the clinic - they don't open officially until eight. It's a small four room clinic with a waiting room, one bathroom, and a lab and pharmacy the size of a closet. Two doctors work in the morning and one in the afternoon. Today, each doctor will see about 25 to 30 patients between 8:30AM and noon.

When the clinic opens, each women approaches the counter, one by one, passing the receptionist a trifold card that is her medical record and indicates that she and/or her infant have government insurance. In Bolivia, the government provides free medical and dental care for pregnant women and infants up to five years old. Women lose coverage six months after they give birth (unless they are pregnant again).

The receptionist asks each women why she has come to the doctor today. Most women cannot understand his question, which is asked in Spanish. The majority of the patients at this clinic are indigenous and live in the hills surrounding Cocahabamba. The receptionist calls the women cleaning the waiting room to come translate his question into Quecha, the indigenous language here.

Most women have brought their small babies in for vaccinations, offered free by the government. One woman has brought in her five year old son for a lab test to see if he has Chagas. Another women approaches the counter with a swollen eye and cheek. She is holding a four month old baby and has a three-year old by her side. Her eye is covered with a coca leaf - a local remedy for anything here in Bolivia from altitude sickness to swelling. Through the translator, she says that she has "fallen down" and hurt her eye. "This is not the truth," the cleaning lady tells me. "She has come in before. Her husband hits her." Yet another women approaches the small registration table with her son. She has a deep cough and chills - perhaps a case of active TB. Another women has a 4 day old baby with her. She is a new patient. The receptionist asks her to write her baby's name down so they can register her as a patient. She cannot write.

One by one, each women is given a small card with one of two doctors names and an appointment time. Appointments are supposed to be 15 minutes, but inevitably last longer. Just forty five minutes after "opening" the clinic, all of the appointment cards have been passed out and the registration table "closes down". The women wait in a small room with about twenty chairs. Some must stand with their babies. Coughing and crying can be heard from those who are not feeling well. A man with a basket of salteñas passes through the clinic and some women begin to eat. I ask if eating is allowed in the clinic. "No..." the receptionist tells me in Spanish..."But it's complicated. Some of these women will have to wait a long time."

The first women assigned appointment times began to spread out down the hallway. A nurse comes to get them - a few at a time - to take their/their baby's blood pressure, weight and height. Any emergencies are also seen in the nurses room. A man comes in with a bloody leg and is sent to the nurses station. If this primary care clinic cannot handle his injury, they will send him to a secondary clinic. Health clinics in Bolivia have three levels. Primary care clinics deal with most internal medicine and pediatric issues - from vaccinations to treatment of Chagas and tuberculosis. Secondary clinics have a few more specialists on staff - perhaps an emergency doctor if they are lucky. Tertiary clinics are actually hospitals. Women go there to give birth, if they can get there in time, and most surgeries and inpatient care takes place there.

Chagas
As I wait to observe the lab and pharmacy, I flip through a binder the "Medicos Sin Fronteras" has put together to log cases of Chagas disease. Chagas is parasitic disease (often called trypanosomiasis in the United States). The typical vector for transmission is a 2 cm triatomine bug that looks like the "stink bugs" I remember seeing while camping as a child. These insects live in the adobe mud that has been used to build almost all of the homes in rural areas. At night, they come out from cracks in the unfinished walls and feed on human blood. After feeding, they defecate on the bite area. The parasites live in the feces. Scratching the itchy bites causes the parasite to enter the body. Often, people will also touch their eyes or mouths and spread the infection. The hallmark sign of Chagas is a swollen eye, aggravated by the parasite. Chagas has two phases - an acute phase and a chronic phase. Treatment (benznidazole or nifutimox) is possible only during the acute phase, which lasts between 30 and 90 days. If not treated (or identified too late) the parasites become systemic. Slowly over the course of several years, they infect the organs, causing swelling that often leads to fatal problems in the nervous, digestive or cardiac systems. Treatment during the acute phase is long and expensive.

Photo from an online article. 

Depicts typical eye reaction to Chagas.

Many of the records in the "Medicos Sin Fronteras" binder that I am looking at show that the people have abandoned treatment - likely because they could not get to the clinic every day for their medication or because the clinic ran out of medication. This particular clinic no longer has medication to help those who have a positive lab diagnosis of Chagas. They have had to tell people who might otherwise be treated that they can either go buy the medication themselves (which is far too expensive for this population to do) or accept the fact that they will have Chagas for the rest of their lives. They will have to be careful not to spread it to family members and are advised to come back to the clinic if they believe they have become pregnant. The parasite can also be spread through contact with blood and through maternal/child pathways.

I ask the head doctor at the clinic if they have done any outreach to education the population, help them determine how to treat their houses with insectiside, and get medical attention as soon as they think they may be infected. She tells me they would like to do this, but since they cannot keep a constant supply of medication to treat people, there is no use in providing education. "There is nothing we can do for people who are infected right now," she tells me in Spanish.

Online photo of typical adobe housing in rural Bolivia

I wonder why there is such an international focus on Malaria prevention when Chagas effects between 8 and 10 million people living in Central and South America....and inevitably causes early death for those infected. After a quick search online, I learn that a successful vaccine has been tested for Chagas, but is too expensive to deliver at a population level. The two medications to treat acute Chagas are both highly toxic and expensive (one is manufactured by Bayer). Bolivia has the highest prevalence of Chagas of any country in the world and Chagas is the largest parasitic killer, yet the entry about the disease on the WHO website is less than a paragraph...

Pharmacy
I wander down to the tiny pharmacy to ask the pharmacist what medications they do have in stock. The government has a program to provide medication for those with active tuberculosis...though none of the medical staff wear masks or gloves and newly infected individuals regularly enter the clinic, coughing as they walk by the packed waiting room to get their medication each day.

The pharmacy has some basic antibiotics (gentamiacin, penicillin and metronidazole) and the pharmacist tells me that they are very lucky to have received a special supply of depo provera to aid in family planning. She tells me that sometimes the doctors ask women with many children if they would like to continue having more. She has a small box of condoms next to the depo provera and tells me they were provided for free by the government but, "they break easily." She adds that men refuse to wear them anyway. While she tells me the deep provera is great to have right now, she recounts some stories of women who got the injection last year when they had the medication. They did not know they needed to come back every three months for another injection and at least one ended up getting pregnant when she did not want to.

It's easy to see why women don't understand how to use their medications properly. I watch the pharmacist tell four or five women in rapid-fire spanish how to take their medications. "Take this one every day rectally," she says to one women. "Take this one morning and night for seven days," she said to another. The women stare at her blankly. They do not speak Spanish and may only understand a few words, yet the pharmacist doesn't speak their language, Quecha. Neither do the doctors. Who knows what they will do with the medications. I ask if she's ever considered giving some visual instructions with the medication. "Why would we do that?" she asks. "It would take more time and I'm telling them how to take it...." In the craziness of health delivery, many staff in this clinic are resistant to any change. Their work is hard enough...

Lab
I shuffle along the wall to peak into the lab. The lab tech is talking to a thirty-year-old indigenous woman about her lab results, which indicate she is positive for chronic Chagas. His equipment is spread out along a small shelf, samples strewn about, some without labels. He uses the same lab gloves over and over, rinsing them out each time. At least he has a set of gloves. The doctors do not use gloves and there is only one bathroom in the clinic, so washing hands between patients is out of the question.

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As I'm about to leave for the day, a women with a baby comes to the reception counter. I fetch the receptionist from the back. Her baby has a fever and she wants to see the doctor. "There are no more appointments today," the receptionist tells her. She can come back in the morning if she wants or she can try to go to another clinic.  Another primary care clinic is likely to be at least 15 minutes away and may not have space for her either.

It's just another day in the public clinic outside of Cochabamba....

RESOURCES:
Doctors Without Borders Chagas campaign
Pan American Health Organization Report on Health in Bolivia
Wanted and Unwanted Fertility in Bolivia

Sugar, Gasoline and Taxis.

 When we are no longer able to change a situation,

we are challenged to change ourselves.

~ Viktor Frankl - from Man's Search For Meaning ~

From my broken/sprained ankle to a week long transportation/worker's strike that has shut the country down, our character has truly been tested here in Bolivia. Last Monday, about five days after arriving in Cochabamba, just when we were due to start working at our much awaited internships, a newspaper article came out that changed everything. The transportation union had decided to raise fares on public transit, run by TRUFIs, or "Taxi RUta con FIja" - fixed route taxis, and Micro Buses. While the fare raise was only from $0.25 to $0.33, it was proposed in a volatile environment as gasoline prices and sugar prices are double or triple what they typically are here due to national and international shortages. 

Naturally, people have blamed the government for these price increases despite the fact that they are tied to international commodities. Bolivia is a country with a rich history of community organization and protest. On Tuesday, the primary workers union, which organizes all of the other unions, took to the streets, blocking the entire center of all major cities in the country. Tuesday was the only day I was able to go to work (Aaron still hasn't been able to get to work). People were throwing rocks through the windows of buildings in the Plaza Mayor and even at TRUFIs and Micros that were still on the roads trying to bypass the blockage. 

Photo of the Tuesday protest that I cautiously snapped from a distance. 

Due to the violence, all public transportation went on strike on Wednesday and Thursday. Because may people rely heavily on these shared taxis to get to work, most businesses and restaurants were closed and people were confined to their homes. On Friday, the worker's union used old tires and boulders to block every major bridge to get into the city, protesting the transportation strikes and demanding increases in their salaries to match the fee increases. It should be noted that they demanded more than a 100% increase in their salaries and refused to meet with the government unless that demand could be met. To give you and idea of the salaries for different professions here, teachers in Bolivia make between $175 and $300 per month, Doctor's make about $350 to $800 per month. You can buy a cup of coffee for about $0.30 and an entire meal out at a restaurant for about $2.00. It should also be noted that in 2006, all government employees received a 13.6% salary increase and a 12% raise in 2009. While the current president, Evo Morales, "laughed" at the request for a 100% increase, we are hopeful that some sort of government/union meeting will occur tomorrow, allowing us to get to work (and allowing offices to open for the day). 

Throughout these strikes and protests, we've quickly come to understand that the pace here in Bolivia is the polar opposite of what we've known in the states. While we've felt cooped up at "home", growing tired of the same five english books and our deck of cards, our Bolivian family (and others that we've observed) seem content to spend the day "doing nothing". Our host family has openly shared with us that Bolivians don't work a lot, usually from 8 to noon or from three to seven. Bolivians enjoy a healthy amount of "descanso" or relaxation. I imagine this might feel different if you are in your own house surrounded by your own community of friends and family. Having only arrived here two weeks ago, this has been a difficult adjustment for us.

We live on the outskirts of town with a nice lower-middle class family - a mother and her daughter who's about our age. In the afternoons, the mother's two grandchildren come over while their mother is at work. Their three-room apartment is on the third story of an older building. About twenty bags of cement mix and an old TV obstruct the entryway as you walk in and some neighborhood dogs are usually roaming the street outside. The apartment building next to us is being renovated by hand and we wake up at 6 in the morning to the sound of a hand operated metal cutter contraption. We'll have to do another post on the construction processes here in Bolivia. The country is in an "industrial revolution" phase, with many multi-story buildings going up. However, they seem to lack many basic building materials and any safety procedures. We've noticed that they use small logs to prop up levels of cement (see photo) and men walk around on top of ten story buildings without hardhats or security scaffolds.

Metal Cutter Contraption next to our apartment building.

 One of the high-rise buildings going up in our neighborhood.

 Example of the wood beams they use to support the cement layers of buildings.

It's been such a valuable experience to learn first hand about the politics and lifestyle here in Bolivia and our "host sister" has been kind enough to introduce us to some of her friends. While I know we will eventually settle in, it has been a challenging couple weeks between the city shut-down, my mobility problems, and such a different style of life. We continue to remind ourselves that life's challenges are supposed to help us discover who we are and what we are capable of, not hold us down.

Los Empacadores ganan el Superbowl!

First things first....the Packers won the Super Bowl!!!!
Yes, I had to sacrifice watching it as we were at 30k feet on a plane for the duration of the game, but in the end it was worth it if it meant that the Lombardi Trophy would be returned to its rightful place. My search for a bootlegged copy of the Super Bowl began the minute our plane touched down in Cochabamba.

Just a quick update...

After a brief 2 days in Lima and an enjoyable 6 hours of "sleeping" in the La Paz airport at 13,500 feet, we are now getting settled in Bolivia with 4 days under our belt.
Our host family is extremely nice and we've already learned plenty about the country just with a few meals between us. The weather has been perfect (forget the 5 hour downpour on Friday) and the people have been extremely nice.
Of course the only hitch has been Gillian's broken/sprained ankle that obviously has limited our ability to really explore and get to the know the city. Having many months to do that, it will all work out in the end but at least we have begun to master the taxi-trufi network out of the necessity of limiting our walking to 4 o 5 blocks.
We start our work next week and we'll see what kind of programs we'll be involved in; Gillian with the public health clinic Cerro Verde and myself with Mano a Mano. Hopefully it will be meaningful work both for them and for us.

As our "trademarked" slogan for our travels through unpredictability states: "vamos a ver"

Everything you wanted to know about Guatemala (and more).

If God has blessed your bus/car/truck,
then you can drive as crazy as you want to.

The only way to carry something is on your head.

 

Used to Seattle pedestrian rules? Right of way here is as follows: 

Buses, Trucks, Cars, TucTucs, Scooters, Bikes, Dogs, Pedestrians. Watch out! 

There is no limit to the number of family members who can ride on a scooter. Helmets optional. 

Need to chat on your cell phone while on a scooter with a baby on your lap? That's fine too!

MTV could fare very well in Guatemala with a show called "pimp my bus"...

Everything you need is at the market and you can usually buy it from one person.

Teamwork is the only way to get something done. 

Below, a team of twelve "sweep" the runway at the airport.

Every wonder where clothes go AFTER Goodwill or the Salvation Army? To Guatemala of course - to a section of the market called "La Paca" because people buy giant packages of US used clothes.

Some type of ice cream bar (or soda pop) will be available in any pueblo - no matter how small or remote (even if they don't have potable water). Below, a girl pokes her head out from her cane and tin house while eating an ice cream bar.

Road work is literally a "brick by brick" task (or shall we stay stone by stone)...

Forget the Rooster, 6AM fireworks are guaranteed to wake you up each morning 

(a birthday tradition here...).

Just when you think there's no more room for passengers in the bus/van/colectivo, 

five more will squeeze in (below - view of a collective from our bus).

Someone is always painting or repainting at least one house on the block, but Sherwin Williams only sells 4 colors of paint: Yellow, Orange Cream, Blue and Mint. 

Never underestimate the number of holidays for virgins or saints. 

(Below, a dance from one of those holidays).

And finally, Guatemala is filled with wonderful people, beautiful places, and great food!

Antigua, Guatemala

Pacaya Volcano

Lake Atitlan

 Monterrico, Guatemala

 Rio Dulce, Guatemala

Guatemala City

 Flores, Guatemala

Tikal and the Peten Region

Traditional Food

Health Care in Guatemala

Between getting a filling replaced at the dentist, working with pharmacists to treat any number of parasites, and spraining my ankle, I have been able to get quite the “insider’s look” at the health care system in Guatemala.

Health care is delivered by a public system, a private nonprofit system, and a private for profit system. Most of what I experienced was in the private system. Besides a few noticeable differences, the care is generally ok in private clinics or hospitals and costs FAR less than we are used to in the US. 

For example, I was able to go directly to a dentist when my filling broke, get a free consult on the spot, and get the entire filling replaced the following day for a mere $20 (which I am sure was the slightly marked up “gringa” price). While the dental work seemed all too familiar, the equipment was about 20 years older and the “patient chair” was in the waiting room (there were no patient rooms or curtains). Throughout the filling replacement, people would ring the front doorbell, the dental assistant would answer it, and they would come in to talk to the dentist (sometimes just stopping by to gossip). She continued working on my teeth as though it was completely normal. My dentists were a husband and wife team who told me they had trained in Guatemala city. The husband was especially proud to tell me that he was also an architect….hopefully just as a hobby?

Me with my dentist. 

She's one of the few female dentists in Guatemala.

My sprained ankle (from a fall hiking in the jungle up north) was another story. We were not near any big cities when it happened. However, I was able to go to a pharmacy (every pueblo has a pharmacy) and get 800mg ibuprophen tablets (and anything else I might have needed) without any prescription. This is how most locals treat themselves – direct to the pharmacy with a request for some medication their friend or neighbor recommended.

After a day or so, we decided it might be good to get some crutches (and possibly an X-Ray?). When we arrived at the public health clinic in the village where we were staying (Fronteras), there was a line of about 30 women waiting to see the doctor. Several pregnant women were smoking outside and other patients were waiting, eating and talking by a fried chicken stand right next to the clinic. As you might have guessed, this clinic did not have any crutches (or equipment to X-Ray or diagnose my condition).

About an hour and a half drive away, we found a recommended private “hospital”. It was only two years old and looked like a cross between a nursing home and a church. The clinic was virtually empty, however, the doctor on staff assured us that he had some crutches. For about $12, I had a consult with the doctor who sat behind his desk and asked me to wiggle my foot. During the $25 X Ray, I had to ASK to wear that heavy apron to protect me from the 1970’s equipment and radiation.  After running to fetch the protective apron, the doctor assured me that they always provide it when someone asks.

 Getting my "Rayos-X"

After my experiences in “private” health care here, you can imagine how interested I was to learn about the public system. I informally “interviewed” a variety of locals…

Public health care in Guatemala (called IGGS or Instituto Guatemalteco de Seguridad Social) is not “free health care”.  Similar to the United States, big companies pay into a healthcare insurance pool. Employees from those companies pay a small portion, and they are allowed use the public hospitals. Those who are not employed by big companies (which is most of the population of Guatemala) can pay 4% of their income (whatever it may be) to access the public hospitals. However, according to those we spoke with, very few people choose to pay for this access, as it is really only coverage for catastrophic care. 

Our host father shared a story about how he went to the public hospital for a chronic hearing loss problem. Not only did they still want him to pay for regular visits with the doctor to assess the problem, but they told him the first visit with the specialist wasn’t available for six months (keep in mind that his hearing was getting worse by the day). He went down the street to a private provider and paid only slightly more for a visit the following day. Insurance options (sold through banks) are only just starting to creep up to help people offset the costs of private medical care.

Poor families, however, cannot afford to pay for care in either the private or the public facilities. In addition, the public hospital (which also includes all of the clinics, from dentists to behavioral health) requires LOTS of waiting, which takes away from time that could be spent working. We heard from our Spanish teachers and host family that sometimes, people will line up outside the hospital the night before and sleep there so they are near the front of the line. Otherwise, going to see the doctor, even for something minor, might take all day (only to hear that you have to come back in six months). Apparently everyone gets in the same line – whether they need dental care, acute care or chronic care. One doctor’s full time job is to assess the line, both for critical patients, and to direct patients to another area where they wait for their specific issue (e.g., dentist, internist, etc.).  You can see while people might try to find an alternative for their medical issues.

Between one quarter and one half of Guatemalans do not have any access to health care services (both because of poverty and the rural nature of certain areas). Guatemala is among the worst performers in terms of health outcomes in all of Latin America, with one of the highest infant mortality rate and one of the lowest life expectancy at birth. The CIA World Factbook ranks Guatemala #143 for life expectancy (granted the US only ranks #49…but that’s another discussion).

Major causes of death in Guatemala still include treatable and communicable diseases, such as diarrhea, pneumonia, cholera, malnutrition, and tuberculosis. Outside the public health clinic that we went to in Fronteras, a small sign with pictures said, “if you’ve had a cough for more than ten days, tell the doctor, you might have tuburculosis.”

A paper I read on this topic (Health and Poverty in Guatemala, Marini, Michele & Marini, 2003), suggested that the following factors limit the ability of public health workers to improve the situation: (i) widespread poverty due to limited household resource availability; (ii) poor environmental conditions; (iii) the limited availability of private sector providers of an adequate quality; and (iv) a general lack of knowledge about the benefits of modern medicine, especially among the indigenous population.

We have personally witnessed all of these in action during our time here. One NGO we worked with that provides nutritional education to mothers and urgent care to children who are dying from malnutrition said that when they first began their project two years ago, women from rural pueblos (e.g., Santa Maria de Jesus where we spent some time) refused to let their dying children be admitted to the clinic for fear that the doctors would eat them. After several children died anyway from malnutrition, one family decided to “chance it”. Their son was saved after being admitted. This has helped the project grow in this community, but others continue to be plagued by a lack of knowledge about modern medicine.

Woman begging on the street with a Goiter. 

Goiter's are commonly caused by a lack of Iodine.

In conclusion, health care in this country, if it is delivered at all, comes from a broken public system and several NGOs who work in health. We learned from NGOs and locals that we spoke with that people are more likely to go to the pharmacist, dentist or eye doctor because of cost. Unfortunately, preventive care has a long way to go in Guatemala - and preventive care is what's needed most. From basic nutrition and health education to maternal/child care, ample work remains.