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A World Apart
Aaron Mitchell recounts his experience at a health clinic in Bolivia |
This past summer, instead of another internship, I joined a work group heading to Bolivia, and fulfilled my long-time desire to volunteer in Latin America. It was my first trip outside of the United States, and I was headed straight from the richest nation in the world to the poorest in South America.
My stay in Bolivia lasted four weeks. After two weeks building with Habitat for Humanity in Santa Cruz, Bolivia's most populous city at 1.2 million people, I relocated forty-five kilometers north to the small town of Montero. There, I spent the second half of my trip working with Curamericas, a nonprofit organization based out of my native Raleigh, North Carolina. Curamericas, through its local affiliate, Consejo de Salud Rural Andino (CSRA), provides primary health care and health education to over 75,000 people. Specifically, Curamericas focuses on preventable diseases among women and children, such as malnutrition, pneumonia, and parasitic infection.
Volunteer work teams from the United States comprise an essential part of Curamerica's program in Bolivia. The teams raise funds in advance so that they can provide medical services free of charge. On occasion, Curamericas teams also bring funding and labor for physical improvements to the clinic facilities. Thus, the Houston-based team that I joined contained a mix of doctors, interpreters, and builders. Not yet having any medical experience under my belt, I spent most of my time with the construction team, helping to build a library at El Hogar Sangrado Coraz—n, a girls' orphanage next to one of the clinics.
Each morning upon my arrival I was literally tackled by dozens of elated six-year-olds, hugging my legs, grabbing my hands, begging me to come see their prized stuffed animal or the gold star that they received on their homework, or asking me to sing with them. Since my level of Spanish did not allow for much conversation, I was glad that my mere presence was enough to bring joy into their lives.
I did spend several days in the clinics, however, and it was during this time that I learned the most about the challenges facing Bolivian health care.
THE CLINICS
I found the clinics themselves to be surprisingly well run, considering Bolivia's poor economy and frequently substandard sanitation conditions. They were very clean, and while the facilities were certainly not state-of-the-art, the clinics were sufficient for dealing with the problems they encountered most frequently.
The Bolivian clinicians and medical staff were all highly dedicated and confident that their work was making a difference. They eagerly described to us a newly instituted awareness program to battle tuberculosis and asthma. Asthma is severely undertreated in Bolivia, partly because it is just now becoming recognized as a disease. At the same time, the clinicians expressed deep concern over the poor state of public health in Bolivia.
UNWANTED CHILDREN
The clinic workers described infant malnourishment as one of the greatest challenges in the Montero area. Underlying this, they said, was the problem of unwanted children. When children are born from unplanned pregnancies, parents are often financially unprepared or otherwise unwilling to invest in health care. According to the medical workers that I met, much of this problem is rooted in the culture of the region. Women are expected to be sexually submissive, and they are thus unwilling to say "no" to their husbands and boyfriends. Moreover, Bolivia is thoroughly Catholic, and most women do not feel that they can ask their partner to use a condom. The clinics can teach about, but cannot advocate, the use of condoms and other birth control methods. The clinic is mostly restricted to educating women about their menstrual cycles, and it distributes 28-bead necklaces with a movable marker to help women remember how far into their cycle they are and thus avoid sexual activity around the time of ovulation. This program has experienced success in the households with more acquiescent husbands, but the workers were still frustrated that they cannot do more.
In the end, these unwanted children are often neglected, and sometimes even abandoned. Our team spent one day in a church-run, live-in nutrition center for infants. The center takes on malnourished infants whose parents are either financially unable or lack the experience to care properly for them. They charge only a nominal fee for housing the children and essentially try to nurture them back into good health. Unfortunately, many parents never return for their children, leaving the burden with the nuns.
Few of the children I saw there were in good health. Most appeared under four years old, although their stunted growth made it difficult to judge ages. Their limbs were toothpick-skinny, and many were experiencing hair loss. A disproportionate number of them had permanent disabilities such as cerebral palsy, Down syndrome, and physical deformity. It is sobering to realize that these children, now at least receiving adequate nutrition, are the lucky ones.
HOME VISITS
I had a chance to witness first-hand many of the major obstacles to public health in Bolivia when I joined another volunteer, a resident in pediatric dermatology at the Texas Children's Hospital, in following one of the clinic nurses as she made her weekly visit to a nearby community. A forty-five minute walk took us from the suburban outskirts of Montero into the semi-rural countryside. The economic and hygienic conditions of the residences we passed declined steadily as we moved farther from Montero. Piles of mixed brush and garbage lined the roadsides, waiting to be burned. Houses became smaller and less sturdy, while the frequency of stray dogs and chickens became steadily greater. I also became painfully aware of a key advantage in sanitation that cobblestone-street city centers have over their dirt-street suburbs: their habitants are not as prone to relieving themselves in the gutters.
The community we were visiting was on the far side of a small creek. As we approached the creek, the nurse stopped to explain the origin of the overpowering stench that arose suddenly. She motioned to a cement pipe a few dozen yards upstream, which poured raw sewage from the city into the creek at a steady rate. Her story turned my stomach:
"This is where all of the families come to wash their clothes and bathe their children. I tell them just to go upstream of the pipe, because the water is cleaner there. But I still catch them down at this part of the river every week. And they still wonder why all their children have bugs."
With that, she quickly put to rest any questions we might have had about the source of the community's problems with intestinal parasites.
On the far side of the creek I witnessed the worst poverty that I would see during my month in Bolivia. The community's economy seemed to rest entirely on brick production, and its most prominent features were thus large mixing pits and firing kilns. All of the houses were built of dry-stacked brick walls, without mortar, and thatched roofs. The houses always seemed to be on the verge of collapse.
Our first stop was with a family consisting of a mother and four children, some of whom had begun eating dirt Ð a phenomenon sometimes observed in severely iron-deficient individuals. The nurse tried to explain to the mother what was causing this, and suggested that she try to incorporate more protein (beans and rice, or meat if possible) into their diet, which consisted mainly of corn and yucca root. She had trouble, however, convincing the mother that her children's dirt consumption constituted a serious health problem, both nutritionally and by raising their risk of parasitic infection.
"I don't think it's very bad," responded the mother. "I can understand why they eat the soil. I tried some myself, and it tastes pretty good!"
We made our way to another house, this one empty except for a few malnourished toddlers playing dangerously close to an open fire. The nurse was in the process of condemning the irresponsibility of leaving the children unattended when a man working in a nearby brickyard noticed us and walked over. I could tell from her expression as he approached that the nurse knew him all too well.
The man introduced himself as the mayor of the community and asked what he could do for us. The nurse asked him where the children's parents were. He responded, through a mouthful of coca leaves, that the father was working and the mother had gone to town.
"What is she doing there that is important enough to leave her children alone?"
"Buying coca."
"What a surprise. Always more coca."
The mayor, a young man of about thirty, seized the opportunity to express some of his political views, criticizing at length American policies on coca production, and what he described as destructive American globalization and shallow tourism.
"It's always America's fault with him," our nurse explained as we left. "Maybe America hasn't done anything to help this community, but he hasn't either. He sits and blames America, but does nothing to help his own people get basic medical care."
At our next stop we found a young woman holding a pale, swollen baby. The resident with us quickly diagnosed the baby with mumps. The nurse began to ask her why the baby had not been brought to the clinic for treatment or, more importantly, for the proper vaccinations.
"My husband doesn't want me to."
"Does he say why?"
"He says that doctors do not help."
"Have you told him that your child is very sick and needs medicine?"
The woman looked uncomfortable. Confronting her husband was obviously not something she was prepared to do.
"Why don't you talk to him," she suggested, motioning to a nearby brickyard.
Her husband did not look happy to see us coming. The nurse clearly had a history with him as well. He stood nearly a story below us, a lump of coca in his cheek, shoveling dirt into a pool of the same filthy water from the stream.
"You baby is very ill."
"I don't have time. I'm sorry."
"Don't you think that your baby's health is important enough to stop for a few minutes?"
He said nothing for a few seconds, then tried another excuse.
"I can't hear you. The music is too loud."
The nurse walked over to his radio, turned it off, and tried again.
"Can you at least listen to me while you continue to work?"
She interpreted his silence as an affirmative, and proceeded to describe the seriousness of the situation and the simple, inexpensive things that the clinic could do to help his child. At one point he expressed skepticism about modern medicine, saying that doctors only want money and that immunizations only make people sicker. Our nurse defended her intentions and also gave him a simple explanation of how immunizations work. Finally, she asked him to promise to bring the child in for treatment later that week. He said nothing, but nodded.
"These people," she explained as we walked away, "are so skeptical of any 'new' medicines. They think that doctors will rob them, but then they give what little money they have to the witch doctors instead." Thinking back to the home we had just left, she added, "The baby will die because of him."
Sadly, this was probably true. The week ended with no sign of the family at the clinic.
The rest of the day was slightly more encouraging. We visited several families whose children were enrolled in the clinic's nutrition program. One family had lost two children to malnourishment, and the parents were thankful that their surviving children were faring much better now that they were on the clinic's diet.
EDUCATION MUST BE A PRIORITY
During my visit, it became clear to me that having clean, well-run clinics will not solve Montero's public health problems as long as the available facilities continue to go unused by the people who need them most, and as long as unsanitary practices remain widespread and unabated.
Poverty is certainly one of the inherent obstacles in Bolivia, and the cost of care cannot be overlooked. The Montero clinics charge five Bolivianos, or about sixty-five US cents, for basic services such as immunizations, antibiotics, and parasite testing. While these fees are minimal, they can be daunting for a household earning only a few dollars a day. But if affordability is a problem, misplacement of priorities seems to be an even larger one. The man whose baby was ill with mumps still had enough money for a radio and coca leaves, and the malnourished toddlers at the house nearby had been abandoned for the purpose of buying more coca. Montero will not be able to overcome its public health problems as long as its citizens are quicker to buy intoxicating drugs than food and medicine for their children.
The problem is exacerbated by mistrust and a lack of knowledge about modern medicine. Many of the families we visited were of largely indigenous origin, and have used traditional healing methods, some more effective than others, for centuries. Some of these methods are indeed valuable, but as long as Bolivians prefer them to antibiotics and immunizations, the nurses at the clinics will continue to be frustrated in their attempts to bring adequate health care to the community.
I believe that education is the best hope for addressing many of the predominant health problems in Bolivia. Women must be helped to prevent conception of unwanted children, through education about their rights and options, and by trying to overcome the stigmas ingrained in Bolivian society. The men that I met must be convinced that immunizations can save their children, and that their children's health is more important than coca leaves. And the families living among the brickyards must learn that the nearby stream is the source of the parasites that plague their community.
The Curamericas clinics have indeed made education a top priority. In addition to providing cheap care, they also strive to educate their patients about their illnesses and, more importantly, how to prevent them in the future. There is a long way to go Ð and if the resistance I saw during my stay in Bolivia is any indication, change will not come easily. But, through Curamericas, I also saw a focused, talented and committed group of volunteers and workers who held tightly to their vision of a healthier Bolivia. With enough perseverance, I think we can get there.
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