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
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