- April 18, 2009: Broken System
- February 5, 2009: Parents' Choices
- October 5, 2008: Chagas
- April 29, 2008: Colleagues
- October 25, 2007: Children Die of Diarrhea
- September 10, 2007: Impact
- May 31, 2007: More is Better
- April 28, 2007: Lessons Learned
- March 22, 2007: Mobile Clinics
- Febuary 9, 2007: Health Promoters
- January 2, 2007 : Malnutrition
- November 25, 2006: Medical Realities
April 18, 2009
Medical Letter #12: A Broken System
Teo, our clinic director, walked into my office as I arrived yesterday afternoon and showed me a prescription with various items listed (Cytoxan, IV fluids, various IV tubing, and other items I could not read). She told me that this was the prescription given to one of our patients who has chronic renal failure from Lupus and is being treated with dialysis at the government hospital. Teo told me the total cost of the prescribed items was about $50. The patient would need to pay this at least once a week for her dialysis. The woman makes money by walking around the streets with her baby on her back trying to sell snack items. She may make $50 in about 2 months of work. Teo was asking me if I knew of any organization in the US which would pay for this woman’s dialysis. I looked at her very sadly and replied that I did not. How could a health care system which cannot provide access to primary medical care for over half of its population hope to pay for dialysis for this poor woman who is selling on the streets. These are the tough questions which doctors here face. Without an organized public health system which is affordable and available, only the wealthiest who can pay out of pocket for their medical care receive the necessary treatments.
At this time, the government is trying to reorganize the health care system, but, it is up against many doctors who are wealthy and influential and wish to keep things the same. They are also facing so many crises at the same time that they are overwhelmed. So, what is the answer? With the financial help of Venezuela, Cuba has sent doctors to work in remote areas to provide primary care and ophthalmological care. The system runs completely independently of the Bolivian public health system with the Cuban doctors using their own medicines and providing all of their care for free. There is no coordination with the Bolivian hospitals or physicians who are working in the same areas as many of the Cuban doctors. In fact, the entire medical community is against this policy because there is an abundance of Bolivian doctors unemployed and looking for work. They complain that if the Bolivian government were to pay them the $400/ month that the Cuban physicians were receiving, they would gladly work in remote areas as well. The government has no good response to this, but, I have to admit, the medical society is not running to the table to try to solve the problem either.
My Bolivian colleague, Juan Carlos, has left MAP and is now working as a forensic doctor for the government. It is a better job for him and I am glad he has gotten the opportunity. I miss him greatly and feel as if perhaps the biggest professional impact I have had here is my influence on his development as a young physician. Some day he will enter a pediatric residency and become a great pediatrician. Now, there is another young Bolivian doctor working in the clinic whose father is Cuban. He has many relatives in Cuba and explained to me how this system of sending Cuban doctors all over the world to developing countries works. There is an abundance of doctors in Cuba. Their salary for working there is about $20/month (it used to be about $5/month about 5 years ago). Most of the doctors are now working in restaurants or driving taxis. But, the Cuban government makes deals with many developing countries and NGO’s to send their doctors to areas of need. The countries or NGO’s pay the Cuban government directly. This amount could be as high as several thousand dollars a month. The Cuban doctors are anxious to work in these countries because they often can make several hundred dollars a month with the balance going to the government. The doctors’ families are much better off while they are away with the extra income and the Cuban government makes money in the process. Cuba comes across as a great humanitarian country, but, it is actually using its professionals as methods of income (this is also true with engineers and other professionals). I’m sure many of you who have worked overseas have run into these Cuban doctors as I have in Uganda. This makes some sense for countries which truly do not have the doctors to work in all the areas of need, but, here in Bolivia, it becomes more of a political game. While the government and medical society fight with each other, many Bolivian doctors remain unemployed with only a small number of Bolivians living in remote areas benefiting from the presence of the Cuban doctors.
So, while the political forces fight against each other and the people are confused about whether to go to a Cuban or Bolivian doctor, the country continues to lack an organized public health system. My prayer is that someday everyone will realize that they must work together to improve healthcare for everyone in the country. But, if we can’t even do this in our own wealthy country, what can I expect from a country which is just struggling to survive.
This is my last medical letter from Bolivia. We leave the country on April 30. I have enjoyed sharing my stories with you and knowing that there are listening ears on the other end. I have learned a lot as I have struggled to find my way as a doctor here. I am a bit apprehensive about my return to the US and working within a healthcare system in the condition that it is in at the moment. My hope is with President Obama in office that perhaps our country can someday be an example for the rest of the world by developing a more compassionate health care system for all.
February 5, 2009
Medical Letter #11
Dear Medical Folks:
It was a light afternoon in the clinic as the Christmas season was upon us and many people were traveling. I glanced at my next patient waiting outside the exam room in the arms of her mother. I knew immediately that this was going to be a challenge. As her mom, dressed in traditional indigenous dress and speaking only Quechua, carried in the little 4 kg one year old baby with Down’s Syndrome, I began thinking of a strategy.
She had been seen the day before by Juan Carlos, my Bolivian colleague, and referred to me to see the next day. He had correctly diagnosed her with severe malnutrition, a heart murmur and diarrhea which was proven not to be caused by parasites. Now, it was up to me to convince her mom that she needed to go to the hospital. I knew I couldn’t do it alone, so I went in to ask Maruja, our pharmacist/lab tech/nurse who speaks Quechua, to help me out. She told me that this mom was afraid to take her baby to the hospital because she believed she would die there. The baby had been seen one other time several months back with the same problem and referred to the hospital. Her mom refused to go at that time because she believed they would stick a needle in the baby’s back and take fluid from her and she would die. I asked Maruja to help me talk to her this time and she agreed. Maruja explained in Quechua how important it was for the baby to go to the hospital. The mom first asked if the baby would die there. Then, she explained that she had too many other children to care for and that she could not leave the baby in the hospital because the baby needed to be breastfed. Maruja explained how the breast milk was no longer adequate and that the baby needed treatment for her heart and better nutrition. The mom countered with the concern of getting back to her hometown outside of the city to make sure her house was still OK during the rainy season. We finally came to the agreement that she would return to the clinic the next day with her 16 yo daughter to help out and that one of our staff would take her down to the hospital to assist with translation. She never returned.
This is a very common challenge in our clinic. The combination of poverty, illness, suspicion of the broken healthcare system, and belief in traditional medicine and “healers” leads to children never receiving adequate attention and often dying. Bolivia is a country without universal healthcare coverage, without programs for children with special healthcare needs and with abundant discrimination against the indigenous population. Even though I can do my best to convince parents to take their sick children to the hospital, the reality is that they will always balance the quality and cost of care available to them against the chance that their child could get better using traditional medicine and care at home. And, honestly, I often have a hard time disagreeing with them.
In this case, after much discussion with my Bolivian colleagues in the clinic, everyone was convinced that this mom with other children to care for and the prospect of a sixth child who would be a burden all her life, really wanted her baby to die peacefully at home. They had all seen the same scenario over and over again with children with disabilities and genetic syndromes. At first, I was appalled to hear such a thing. In the US, we would call protective services and have the baby taken away for medical neglect. Not so here in Bolivia. A mother, who is already bearing the burden of all the work in the home, caring for all the kids, and trying to earn money when she can, sees a “defective baby” as an extra burden she just can’t handle. Some may say we have an obligation to intervene and force her to hand the baby over to the hospital, but, you would find very few Bolivians here who would agree. For my part, coming from a country with an abundance of medical technology but, poor access to medical care for all, I have a hard time throwing stones. But, I do have hope that with a more socially minded government in Bolivia that the future holds more hope for this mother living in poverty to have access to the care necessary to believe that her baby can live a healthy life and never consider the option of letting her baby die.
October 5, 2008
Medical Letter #10
I saw Marcos’ babysitter Marlen sitting on a bench at the school next to the clinic waiting to pick him up. Marcos is one of Josh’s good friends. One of her eyes was swollen shut. The other looked fine. When I approached her to take a closer look, I asked her what had happened to her eye. This young indigenous woman from the countryside dressed in traditional clothing was very shy and hesitated to speak up. At first, I thought she might have been hit by someone in the home (unfortunately, a very common occurrence). Then, I thought it looked more like an allergic reaction to an insect bite. I suggested that she take some antihistamines and come to the clinic if she wasn’t improving.
The next day, while I was working in the office next to my Bolivian colleague, Juan Carlos, he called me in to see a patient with “Romana’s sign” indicating the possibility of acute Chagas Disease. Much to my surprise, I walked into his office and saw Marlen with her swollen eye lying on his exam table. I was both embarrassed and scared that I had missed one of the most common diseases seen here in Bolivia, American Trypanosomiasis, or “Chagas Disease”. Marlen was asked by Juan Carlos and Maruja, our lab tech, to try to capture some of the beetles which live in her home and transmit the parasite – Trypanosomiasis cruzi. If she was able to catch them, Maruja could extract the stomach contents and look under the microscope to detect the parasites. This would make the diagnosis likely and she would be referred onto the Ministry of Health to receive a confirmatory IFA (indirect fluorescent assay) and eventually be treated. Her home would be inspected, fumigated, and the adobe brick would be sealed with plaster to prevent the beetles from living inside. The other options for testing, which have a very poor yield, are looking at her own blood directly under the microscope to find the parasite or place a group of young uninfected beetles in a cup taped to her skin allowing them to feed off her blood and examine their stomach contents later to detect the parasite.
All of these basic methods of detection are still used in some areas of the country. But, now the government has made rapid test kits available to detect the antigen of the parasite in drops of blood. If the test if positive (approximately 98% sensitive and 95% specific), the patient is referred on for confirmatory Elisa testing. If confirmed, these patients will receive free treatment of Benznidazole for 1 month. If successfully treated in the acute stage, all the complications of cardiomyopathy, toxic megacolon, and dementia, which occur up to 5-30 years later, can be averted.
Unfortunately, approximately 40% of the population of Bolivia is already seropositive for Chagas including 70% of the population living in rural areas. This is amazing! The vast majority has never received treatment because the acute phase was never detected and treatment in the latent phase (which can last up to 30 years) is not effective. So, all of these adults are sitting on a “time bomb” of disease. After several years of an asymptomatic period, 27% of those infected develop cardiac damage, 6% develop digestive damage, and 3% present peripheral nervous involvement. Left untreated, Chagas disease can be fatal, in most cases due to the cardiomyopathy component. But, Bolivia does not see thousands of people dying of the complications of Chagas because they usually die of other causes prior to the diagnosis of Chagas. Some of these causes may be related to underlying Chagas, but, those statistics are not well tracked.
Still, everyone in the country knows about the disease. Children are taught what the beetles look like so they can report the problem to their parents. They all learn that the beetles live in the walls and roofs of adobe homes and drop their feces on the skin of people sleeping below causing them to scratch and inoculate themselves with the parasite. I asked a cardiologist about the number of patients he sees with complications of Chagas. He told me that about 30% of his in-patient population (mostly poorer patients) is being treated for cardiomyopathy secondary to Chagas.
I have read that with a modest investment, the country could eliminate Chagas Disease. It would have to be a multi-pronged approach with screening of children, inspection of homes, fumigating and improving the homes, and free treatment for all of those infected. Bolivia is getting started in this effort. Let’s hope when things settle down a bit politically, the country can become a bit more aggressive with their campaign. But, as with all diseases in the world which affect the poor disproportionately, we are very slow in taking action to eliminate them.
In the meantime, young Marlen’s blood did not contain any T. Cruzi. She never brought in any beetles from her home and her test at the referral hospital was negative. I rested a bit more calmly and will never mistake a single swollen eye for an allergic reaction again.
Medical Letter #9
Dear Medical Folks:
As I sit in my “consultorio” waiting for pediatric patients to be checked in by our clinic nurse, I notice that there is a crowd gathering in the waiting area. I look and see several mothers with young children waiting and assume that there is just a big back up waiting to be checked in. But, then, as I playfully engage the children and they laugh at this crazy gringo doctor, I begin to ask some of the moms if they are waiting to be seen by the doctor. Several of them tell me that they are waiting to see my Bolivian colleague, Juan Carlos – a general practitioner. I acknowledge their choices and return to my office to ponder this phenomenon.
I have been working in the same clinic for about a year and a half. Many of the parents and grandparents bring their children to see me and I’ve developed a rapport with the entire community. When I walk down the road or take public transportation with my own children, I hear many voices calling out “hola doctor!” It makes me feel as if they recognize me and trust my work. Yet, still after all this time, many parents prefer to see my Bolivian colleague instead of me. At first, I believed this was because of my poor Spanish and their inability to understand everything I said. Later, I realized that although Juan Carlos is an excellent doctor with good diagnostic skills, he tends to prescribe more medications than me, especially symptomatic meds. Many parents want to walk away from the visit with something more than just Acetaminophen and advice to “wait it out”.
Being an experienced pediatrician, my pride was a bit injured even though I realized my limitations. But, now I am gradually coming to understand and realize a few important lessons:
1. I have a new appreciation for foreign doctors working in this US who face patients who say, “I don’t want to see this doctor. She can hardly speak English.” Often, the reality is that many of the foreign doctors are just as skilled as I am working here in a foreign land.
2. Every patient has his or her own preferences when it comes to whom they wish to see for medical attention. There are still many parents who wish to see me. But, I realize personal preference here is not unlike that in the US where I faced similar situations.
3. No matter how much I believe I am accepted and trusted in the community, I am not a Bolivian. I have not lived their lives and do not fully understand their experiences. This is an extremely important lesson for me to learn as a missioner.
4. Finally, I rejoice in the fact that parents and patients prefer to see Juan Carlos. Recently, we have been able to have many small conferences and discussions regarding pediatric care and I believe we have taught each other quite a lot. In the end, the most important professional legacy I can leave behind here is a well trained and compassionate Bolivian doctor who can assist his community for his entire career. I believe Juan Carlos is becoming that doctor. For this reason, I believe I will continue to encourage my patients to place their trust in him and I am sure he will do the same for me.
October 25, 2007
Medical Letter #8
Children Die of Diarrhea
One morning last week as Becky and I arrived at the clinic, she told me that she saw Juan Carlos, my Bolivian doctor colleague, running up the road carrying his doctor bag. I walked into the clinic and asked the nurse where he was going and she said someone had come to bring him to see a patient. I waited for awhile and got started seeing patients in the clinic. Juan Carlos arrived back fairly soon and I asked him what had happened. He told me that a 13 month old child had died overnight and the family discovered him dead in the morning. I asked him what the child had died of and he told me that the child had been into the clinic three days earlier with Amoebas. At the time, he had diarrhea and vomiting, but, was well hydrated and active. Juan Carlos prescribed Metronidazole and told the mom to give plenty of fluids and return in a few days for another exam. Apparently, the child continued to vomit at home and could not keep the medicine down. The family brought the child to a “curandero” (traditional healer) who performed a healing ritual. However, he became increasingly dehydrated and died. I was shocked. This child lived only a 10 minute walk away from our clinic and yet he died of dehydration. I thought this only happened in the countryside where there are no doctors and clinics. I thought there was so much information out there about diarrhea and the dangers of dehydration that every mom knew what the danger signs were. The most surprising thing for me, though, was how easily Juan Carlos accepted the death of this baby. I was doing my best to consol him thinking that he may carry some feelings of guilt or blame (even though he did everything correctly) or that he may consider this death a great injustice. But, he did not. He went on with his work and the rest of the day without any obvious affect from the death. Obviously, he has seen death before many times and accepts that it is a part of life. However, I felt as if somehow we had failed this family. Maybe it was their faith in the traditional healer which kept them from coming back earlier. Maybe it was the lack of free time to bring the child back to the clinic in the midst of their busy lives. In the end, the family accepted the death because children die of diarrhea in Bolivia. As strange as that seems to us North Americans, it happens.
The infant mortality rate in Bolivia is about 75/1000. The under 5 mortality is about 69/1000. This number is much larger in the rural areas where children die of diarrheal illnesses every day. There has been a major decrease in child mortality with the institution of government sponsored free medical care for pregnant women and children under 5 years old over the past several years. But, coverage is very restricted and the combination of the maldistribution of doctors and nurses toward the urban areas and away from the rural areas as well as the difficult terrain of the country creates a barrier to health care which will always be a challenge. Diarrhea and respiratory illnesses continue to be the leading cause of death in children after the newborn period. Clean water and sanitation is still a dream for many communities. The immunizations given here only include BCG, Diphtheria, Tetanus, Pertusis, Hep B, measles, mumps, rubella and yellow fever. Cervical cancer is at the top of the list for cancer deaths in the country despite availability of PAP tests in local clinics indicating the need for better access to healthcare for women and institution of HPV vaccine. One of the advantages that Bolivians do have is the small amount of HIV here. The prevalence is about 0.1%. However, this is increasing every day. There are many challenges which can be taken on by the government as well as local communities. It motivates me to get out of the clinic a bit more and into the community to learn as well as teach. I am starting to do this a find it much more rewarding.
As far as the continuous flow of pediatric patients who come into the clinic for diarrhea, I will be a bit more compulsive about explaining the signs of dehydration in the hopes of preventing another death.
God Bless and Happy Halloween,
September 10, 2007
Medical Letter #7
Dear Medical Folks,
Since returning from our vacation to the U.S. this summer, I have not been able to get into the swing of things again. I’ve had lots of other obligations, illnesses, and commitments which have kept me away from my medical activities. I’ve also been feeling lately that just seeing pediatric patients in my small neighborhood clinic is not enough to feel as if I am using all the skills that I have to offer. For the most part, the patients I see in clinic have the same variety of viral infections that I saw when I worked in the U.S. In addition, I see an abundance of diarrhea caused by both bacteria and amoebas. My Bolivian colleague who works right next door to me in the clinic can treat these conditions as well, if not better, than me. Unfortunately, the hospital where I was going once a week to precept interns has decided to stop its internship program so I don’t go there anymore. I’ve been contemplating other activities such as teaching in the health promoter training program and assisting the staff serving children with disabilities in the community. But, it just seems like as soon as I try to pursue one of these other activities, something pops up and prevents me from moving forward. I still come to the clinic and put in my time for which the staff and community are appreciative. But, I don’t feel like I used to when I worked in Uganda and saw countless numbers of seriously ill patients with malaria, meningitis and HIV. Even though the work was often frustrating, I felt as if I was making a difference.
Then, today I went to clinic and it all seemed different. I started out by seeing a newborn baby who had just been delivered in our clinic by our nurse at 5 AM this morning. I could rejoice with the new father by reassuring him that the baby was perfect. Then, I saw a 2 year old with severe mumps brought in by a Quechua (indigenous) mother who hardly spoke Spanish. Yet, I worked hard to explain what was happening with her child and the complications of otitis and adenitis which the child had. Next, one of the teachers from the school brought over a 4 year old with acute hepatitis. Fortunately, his father was just coming to pick him up and I could explain how his illness most likely was from a virus and he should do well if he rests and drinks lots of fluids. Finally, one of the community health workers brought in a 3 year old girl from the countryside with myoclonic seizures and developmental delay. The mom only spoke Quechua, but, I was able to explain what I thought was going on with the help of a translator so that our team was able to get her an appointment with a neurologist the next day.
There was very little intervention or treatment involved with any of these patients apart from doing my best to explain the origins, symptoms, and outcomes of their diseases (while struggling with my Spanish). Yet, somehow, I felt a bit different. I felt as if having a pediatrician around to diagnose and recognize these conditions was somehow valuable. It’s hard sometimes to feel like my presence here is not having such a major impact. It’s hard to accept the fact that I probably won’t be able to influence the systems which affect the health of most Bolivians before I leave. Yet, when I focus on the relationships which I make and cultivate just by being around and being available, I can see where I make some differences and where personal change can take place in those I encounter and inside of me.
Medical Letter #6:
More is Better
May 31, 2007
Dear Medical Folks,
One of the staff members working in our program for persons with disabilities brought her 4 year old child into our clinic with a prescription written by a doctor from another office. On the prescription was written the following medications:
1. Ceftriaxone 250mg IM x 1
2. Cefuroxime 100mg IM Q8 hours x 4
3. Amoxicillin 250mg PO Q8 hours x 7 days
4. An expectorant
Her daughter had been sick with a cold (most likely of viral origin) for about 3-4 days. She had already been seen in our own clinic by one of my Bolivian colleagues and was given an injection of a concoction they have here made up of 3 types of penicillin (procaine, benzathine, and sodium) along with Bactrim. Now, she was coming to see me because the mom could not afford to pay for all the injections prescribed and her daughter still had her cold after 4 days. After looking the child over very thoroughly, I just could not justify giving any of the medications previously prescribed. Thus, began the challenge which I face each day in our clinic and when I go to the local hospital outpatient clinic to teach med students and interns. I have to explain in my less-than-perfect Spanish the difference between viral and bacterial infections and how antibiotics will not change the course of the illness.
It seems as if in the U.S. there has been a swing away from the constant demand for antibiotics and cold medications by parents of kids with viral illnesses. I attribute this to the publicity of the emergence of resistant strains of bacteria due to the abuse of antibiotics. However, I do remember trying to defend my decision to parents not to use antibiotics constantly when working in both private practice as well as hospital clinics in the U.S.
Here in Bolivia, it seems like the policy is “more is better”. Patients and doctors love injectable drugs. The thought is if you get an IM injection of anything, you will get better faster. Some of the injections given are:
-triple penicillin shots for “tonsillitis” sometimes given for 3 days in a row.
-one dose of ampicillin
-dexamethasone given along with a single dose of an antibiotic to “decrease the inflammation caused by an infection”
- Vitamin B for inflammation
I have rarely found an occasion when these injections were truly necessary or when an oral alternative would not have been preferable. However, trying to explain this to my Bolivian colleagues is almost impossible because not only has it been ingrained in their heads, the patients demand it.
Also, the phenomenon of combination drugs seems to be the norm here. Often, if you go into a pharmacy and ask for amoxicillin (which you can do without a prescription), they will sell you a combination of amoxicillin with aminophylline, or decongestant or cough suppressant. A fellow missioner’s child was recently prescribed amantadine combined with 3 other symptomatic cold medications. This makes it even more difficult to prescribe exactly what I want.
So, I go on with my explanations of viral infections and try to explain why I am only prescribing an antipyretic. Parents listen intently trying to understand. I try to include as many of the natural herbal remedies as possible as I get to know them. Yet, I am often humbled as they leave my exam room only to go to another Bolivian doctor (sometimes in my own clinic) in 2 days as the cold has not gone away seeking an injection and receiving one.
Medical Letter #5
April 28, 2007
Dear Medical Folks:
It has happened to all of us at one time or another if we have been in medicine very long. I remember being a pediatric intern in Richmond, VA and covering the normal newborn nursery one month. As I was leaving for the day, a nurse informed me that one of the newborns had a fever. I looked at the vital signs sheet and saw a maximum temperature of 100. I looked at the baby and he looked fine. I went home and returned the next morning to find that the baby had been transferred to the NICU overnight with fever and meningitis. He died by the end of the day. I believe for all of us, there have been at least one or two patients who we believed were not very ill and sent them home only to find out later that they had developed some serious condition for which they were hospitalized and possibly died. This is part of being a health care provider and, more so, part of being human.
I saw the little 1800g premie in the outpatient pediatric clinic of the small rural hospital where I volunteer one day a week. The mom brought the baby in because she was sent home from the big government hospital downtown after a 10 day hospital stay. The baby had been born at about 30 weeks gestation and had no pulmonary problems. They started orogastric feedings in the hospital and sent the mom home with a prescription for 10 new feeding tubes, syringes and instructions to feed the baby formula or breast milk every 2 hours. She was also supposed to change the tube every week and find someplace to have the baby seen for medical care. The mom showed up at our hospital only a few days after being discharged because the baby had pulled out the feeding tube and she didn’t know how to place it back in. The pediatrician in charge looked at the baby briefly and gave the mom a speech telling her that if she doesn’t breast feed the baby soon that he will lose the ability to suck. He had no other help to offer and told her to return to the government hospital which discharged her. I was left in the room with her looking very discouraged and concerned. I replaced the OG tube with the other pediatrician present and listened to make sure it was in the stomach. The baby was fine afterward and I felt as if I was of some help to the mom and impressed my Bolivian colleague at the same time. I increased the feedings, advised the mom to return to the other hospital to get her supplies and to return to the clinic in a week. She left fairly content.
One week later, I returned to the hospital looking forward to seeing the baby again. After rounds, the other pediatrician, who is also the director of the hospital, called me into his office. He bluntly informed me that the baby I had seen the week before and placed the tube in, was brought to another clinic the next day very sick and transferred to the big government hospital where he was born. He later died from suspected sepsis. However, someone told the mother that the real reason he died was because his lung was punctured by the OG tube. I felt shocked, sad, embarrassed, and guilty. I tried in my stumbling Spanish to talk through the case with the other pediatrician. He agreed with me that it was impossible for me to have punctured the lung, but, offered no other consolation or affirmation. I returned to the clinic feeling as if any progress I had made in gaining the respect of the supervising pediatrician was lost. As I was supervising the medical students that morning, he constantly came into the room to check up on me and make sure I wasn’t doing anything he didn’t approve of. I felt as if every question I asked him was taken as a challenge to his knowledge when I was just trying to learn about how pediatrics was practiced here. By the end of the morning, I returned home dejected and humbled.
After discussing the situation with Becky and reassuring myself that I really did nothing wrong, I realized that not only was I dealing with another one of those situations when the unexpected happens with disastrous results, but, I was also dealing with the culture of medicine here in Bolivia which does not allow for open discussion and questioning between doctors, interns, and students. The system perpetuates itself by reinforcing to students that questioning is a direct challenge to their professors and critical thinking is replaced by regurgitation of details while standing over a patient’s bed on rounds. I really find no one at fault in this system because I don’t think anyone has been shown any other way of teaching, learning and communicating. What I do find refreshing is that the students and interns are yearning for an alternative to the old ways of doing things. So, instead of giving up and never returning to Tiquipaya Hospital to work with the interns and students, I continue to go every week and ask them questions like: “What do you think is happening?” and “What do you think we should do?” and “What other possibilities are there?” instead of just telling them to give patients shots of penicillin without knowing why. In the meantime, I have to accept my own limitations and mourn for a patient who unexpectedly died.
March 22, 2007
Medical Letter #4:
The call came to our house at about 8AM on a Sunday morning. Becky answered it because I was trying to sleep in for the morning. However, it was the coordinator of the clinic – Teo. She asked Becky if I could come along with Juan Carlos – the Bolivian doctor in the clinic and her to give vaccines and do well child checks in the barrio “Pucun Pucun” at the top of the hill on the “skirt of the mountain”. Becky told her that I was still in bed and asked when this trip would take place. Teo calmly answered that they were leaving in 30 minutes and that I was driving the truck up the hill. Becky quickly woke me up knowing that this was something I wouldn’t want to miss and I gathered myself together to run over to the clinic. Our team consisted of Teo, Juan Carlos and I. We were armed with all the vaccines that our patients would need as well as juices and popcorn to hand out as treats. I drove the old beat-up Land Cruiser straight up the mountain until there were no more houses. The local community leaders had us set up in a newly constructed community center which the community was finishing while we were doing our check-ups. I was thrilled to finally be out of the clinic to see how my patients and their families truly live. Teo and Juan Carlos set up the scales and the exam area rapidly as they have done so many times about once every month with these mobile clinics. I just did what I was told to do and marveled at the desire of newly arriving families from the countryside to get their kids checked and vaccinated. I also watched in awe at the entire community working together to complete their community center. Men, women and children were digging dirt to plant new grass, laying down tile flooring, wiring the building for electricity, and putting in new windows. They were laughing and enjoying each other’s company while the building slowly took form. In the meantime, I saw several kids with scabies, intestinal parasites, and malnutrition who had recently migrated with their parents from the countryside to the fringe of the city in order to find work and seek out a better life. By the time lunchtime came, we had seen about 30 kids and given out 40 vaccines to both children as well as adults (yellow fever). The community was still going strong finishing the building and was taking a break to enjoy some “chicha” (homemade corn wine) and sodas before getting back to work. We packed up our stuff and headed back to the clinic to enjoy the rest of our Sunday.
This experience of witnessing the community come together once again to build their own community center as well as see that their kids receive proper medical care made it well worth the effort of getting out of bed that Sunday morning. Several of the kids I saw that morning followed up in our clinic down the hill and now feel as if they have a medical home. I was proud of how well our team worked together and am looking forward to the next trip to the “skirt of the mountain”.
By the way, I am now seeing patients on my own and establishing myself as the local pediatrician. The only other pediatrician anywhere close is in the hospital where I work once a week to get experience teaching medical students and interns. I am still learning a tremendous amount about how differently medicine is practiced here and gradually seeking out ways to help out. I love working with the students and interns who rarely receive any positive feedback. I also get along great with everyone in the clinic which helps tremendously. One need I have been able to fill is providing up to date pediatric books and articles for the clinic as well as the hospital. These can be easily copied here and distributed to the doctors and students. These types of resources are sorely lacking. I have also been able to determine which type of equipment and medications are needed in the clinic and have been contacting some of you for help in getting some of these items. I would not be able to do any of this without the donations many of you have already made to Maryknoll Lay Missioners in our names. We are greatly appreciative. I also want to thank many of you who have helped me out with some of my diagnostic dilemmas. I will try to include all of you in on these in the future.
For more information about how we are all doing down here and more about Maryknoll, please visit our website at www.familysherman.com.
February 9, 2007
Medical Letter #3
They came from all over the Department of Cochabamba and North Potosi; a few from the city, but, most from the campo (countryside). Most of them were only 17-19 years old with some as young as 15 and a few in their 30’s. They all were here at MAP Bolivia (Medical Assistance Program) to represent their small villages and learn how to be health promoters - Roxanna, Arturo, Celena, Alex, Marco, Eliana, and many more – over 40 in all, in 3 different levels of training. I sat with them on their first day of a 5 week course in the meeting room where they would eat all their meals, meet for morning reflection, and learn most of what they would take home with them at the end of the course. All the men were sitting together separately from all the women. The facilitators began the discussion with the schedule and rules of the Training Center. The schedule ran from 6AM – 10PM and was packed with activities and classes. The rules all centered on group responsibility and participation. Everyone had to contribute to the work of cooking, cleaning, and looking out for one another regardless of gender or place of origin. For many, these were brand new concepts. For others who had been there before, it had become a way of life. They were all shy and slow to speak up, but, the facilitators emphasized that all of them would have to participate in order to make the course work. They all agreed to the rules and their adventure began. I was just an observer, still struggling to understand Spanish as it is spoken softly through the closed teeth of a campesino. But, I would come to bond with this group of young kids and become amazed at how well they worked together as a group to improve the lives of the people living in their communities.
Over the next 5 weeks, I watched how a talented group of facilitators (with only a few medical professionals) were able to use popular education, problem based learning and multiple other modalities to slowly form these young men and women into knowledgeable, confident, and motivated promoters of holistic health in their communities. They all made rehydration fluid together out of bananas and potatoes. They learned how to assess the degree of dehydration of an infant using sock puppets. They learned how to assess the dynamics of functional and non-functional families by analyzing drawings and performing dramas. They learned about malnutrition by asking each other what kinds of foods are available in their communities and growing their own vegetables while they were here. They were able to systematically breakdown complicated cases of disease outbreaks in their communities by working in teams to identify questions to be answered and resources to obtain the answers. They learned organic farming. They learned how to seal an adobe home to prevent beetles carrying Chaga’s Disease from entering and infecting the inhabitants. They learned how to build latrines and disinfect water using the UV rays of the sun. They learned about women’s and children’s rights and their role in the community to protect them. They built model communities out of cardboard, stones, and dirt in order to demonstrate how to design health environments in their communities. They even learned how to cut hair.
At the same time, we laughed together about my Spanish and their desire to speak English. We played basketball together until 10 PM at night as I stood under the basket getting all the rebounds as if I were Yao Ming (at 5 feet 11 inches). They danced, ate, and laughed constantly at each other’s antics as any teenagers would.
Then, tonight, at their graduation, they were asked what lessons they learned from the last 5 weeks. Their responses had little to do with how to diagnose illnesses in their communities. Instead, they made statements like these:
“I learned that as a resident of the altiplano (high country) that I can eat, sleep, work, and learn alongside a fellow Bolivian from the tropics without feelings of discrimination.”
“I learned that the holistic health of a community can only come through the motivation of the people who feel empowered to make a change.”
“I learned that as a man, I can share the duties of cooking, cleaning, and caring for my children with pride instead of shame.”
Those same shy quiet kids who met in that same room 5 weeks ago were now all sitting proudly, with men and women sitting next to each other, anxious to tell others what they learned and how they were going to implement those learnings in their home communities. I sat in awe thinking about the impact these young people will have in their small towns and villages as I wondered why we can’t do the same thing in the US. I can’t wait until the next group arrives.
January 2, 2007
Medical Letters #2:
As I was chatting with the “internos” (students in the sixth and last year of med school here) at Tiquipaya hospital ( a very tiny rural hospital where I work one day a week), we were called in to see a 10 month old infant for dehydration and diarrhea. As I walked into the “sala de internacion para los ninos” (a small room with 6 cribs lined up in a row), all the cribs were empty except one. A mom was sitting next to her little infant boy trying to spoon in oral rehydration solution which he was refusing to drink. It was obvious to me immediately that this infant was malnourished. He was crying with tears and his mouth was moist. Most likely, he had one of the big 3 causes of diarrhea here – viral (mostly rota), E. Coli, or amoebas. But, the ultimate issue was discovered as we examined the growth chart and saw a fall from the normal growth curve to the “leve” (mild malnutrition) area of the chart over the last 4 months. After the intern asked all the required questions about the diarrhea in a very stern and impersonal manner, I asked the mom privately about the baby’s feeding history. As it turns out, she fed exclusively from the breast until about 6 months when she started to introduce potatoes and fruit and cereals as all mothers seem to do. But, when I showed her the growth chart, she admitted to me that she had not had enough food in her home during the last 3-4 months and that her breast milk was diminishing. She admitted that the baby is thin because there is not enough food.
As we examined the infant, we saw the irritability, worried face, the loss of subcutaneous tissue in the lower abdomen and thighs. I mentioned to the ER doctor who took her back to the ER because he believed the baby may not be admitted that I believed the primary problem was malnutrition. He agreed, but, said we must manage the diarrhea first. As I listened to him explain the dilemma in Spanish, I believe what he said was that we can treat the diarrhea and dehydration, but, we can’t do anything about the lack of food in the house. I was immediately reminded of our pediatric HIV clinic in Uganda where I used to work. I remembered seeing so many malnourished infants and children everyday not knowing whether they were infected with HIV or not. Often, their nutritional status had little to do with their HIV status. What mattered was whether or not the family could afford to buy food for the child. There, in Uganda, we had a nutrition clinic where we could teach parents about how to prepare what food they had in a nutritious way and hand out some small bags of food to get them through the week. We used to see babies grow right before our eyes because they finally had some food to eat.
But, this is not Africa. This is Bolivia. I don’t see malnourished kids everyday. Here in Bolivia, HIV is very rare (but rapidly increasing in incidence). There are only 7 known infected children in all of the city of Cochabamba. But, malnutrition not only exists, it is very common especially in the more rural areas. It looks the same in Africa as it does in South America. What I am realizing more and more now is that true medicine/healthcare does not stop at rehydrating the malnourished dehydrated child. It goes even further than providing a nutrition clinic for food handouts each week. Not that these efforts are not essential and should not be done. It is just that until the root causes of a mom’s inability to feed her baby are addressed, we will never advance the “health” of individuals, communities, countries, or the world. What are the root causes? They are most likely different in each family/community/country. But, they are rooted in issues of social justice, discrimination, family and community support, economic and political participation- hardly issues taught in medical school or thought to be dealt with during a doctor’s visit. But, maybe we need to start asking more questions and not being afraid of finding out things for which there are no easy answers.
November 25, 2006
Medical Letter #1
Dear Medical Folks:
This is the first of what I hope to be a series of letters sent to you, friends of mine in the medical field. I will try to give you a more personal glimpse into my experience as a healthcare provider here in a small community in Bolivia. If you wish to forward these stories onto others, please do so. If those others wish to be included in our general e-mail list, please let me know. I will also post these on our website at www.familysherman.com.
She walked into the exam room with her husband by her side very quietly and somberly. I was seated behind a desk next to Juan Carlos, the Bolivian doctor with whom I’ve been working over the last week or so, as the couple sat in front of us. I immediately noticed how pale this 60 year old woman appeared when she opened her mouth and her tongue was almost white. Her eyes were puffy, extremities swollen, and she seemed very weak. My Bolivian colleague, a general doctor, looked at her chart and noticed that she was last seen a few months ago for follow up of her Type 2 diabetes. Her blood sugar was in the 300’s, BUN 125, Cr 12, and blood pressure 160/110. She had been prescribed several medications including Lasix and insulin, but, she stopped taking everything except the insulin because she couldn’t afford all of the medicines. She had gone to a natural healer who prescribed herbs, but, she continued to feel worse. She even visited the big public hospital downtown where the only dialysis machines were, but, they wanted to put in a central line and dialyze her right away. She was afraid of the central line and could not afford the $40 it cost for the dialysis. Several people were called into the room to give us support in trying to manage this woman’s situation including the nurse, pharmacist, and health visitor. In the end, more Lasix was prescribed and given to her along with a referral to a nephrologist back at the public hospital. As the couple quietly walked out of the office, I had this sinking feeling in my stomach that I might not see her again.
This was one of my initial experiences with medicine here in Bolivia. I have been away from clinical medicine for over a year preparing for my life as a missioner. I feel as if I am starting all over again as a medical student. Even after studying the language, I struggle to understand my Spanish speaking patients and use my Spanish speaking Bolivian colleague to translate their Spanish into his Spanish to see if I understand it any better. The medicine is not particularly complex. Writing a chart note in Spanish is extremely complex. I have visited about 10 different hospitals and clinics around the city and Becky and I have decided to work with a center called MAP International. It is located in a small barrio outside of Cochabamba called Chilimarca. The reason we chose this particular place is the environment of openness and welcoming which we encountered as well as the variety of programs it offers from primary medical and dental care to counseling for sexually abused children. Juan Carlos is a wonderful teacher. Although he is much younger than me, he is patient and willing to teach me what I need to know. He also is appreciative of anything I can teach him about pediatrics. This is very different from what I have experienced in other clinics and hospitals where doctors are very formal and authoritarian. I am intimidated by them and they are probably intimidated by me also. As a result, very little open conversation takes place between us. I usually talk to the medical students who are more than willing to have someone to talk to who isn’t going to pimp them with questions. I’m sure this will improve as time goes on, but, it is part of the medical culture here which I will have to get used to.
Bolivia is a very poor country with all the pitfalls that go along with that status. Infant mortality ranges between 35-70/1000 live births depending on the area. The distribution of doctors is skewed as in the US with the majority concentrated in the city. About 90% of the doctors are general practitioners, with very few quality residency programs available in the country. Most specialists need to move to another South American country or Mexico to receive training. There is a tiered public health system with “postas” located in the barrios and countryside staffed by a general doc and “secondary level” hospitals in each municipality staffed by a pediatrician, surgeon, Ob-Gyn, and internist. There are one or two “tertiary level” hospitals in each department (similar to a state) manned by subspecialists which also have intensive care units. There is also a government sponsored health program which covers all medical care and essential medicines for pregnant women and children up to 5 years old as well as the elderly. This system, although a start, is grossly inadequate because it only attaches a very limited selection of medications to certain diagnoses making it very difficult to choose the appropriate treatment. As a pediatrician, it is assumed I would be in a hospital receiving referrals. However, I prefer to be in the community where I can participate in more than just direct patient care. I do go to rounds once a week at the children’s hospital in the city and spend a morning a week at the local secondary level hospital observing. But, where I feel most comfortable at this point is at the MAP clinic alongside of Juan Carlos struggling to understand, speak, read and write Spanish in a supportive atmosphere. Ultimately, I hope to be of some help.