A few nights ago Nitin, Rachel and I all reflected on the most unique parts of Bolivia that we observed and will take away from this experience. Rachel talked of the familiarity and warmth that perfect strangers freely give. Nitin spoke of the preservation of the vibrant culture, one aspect of which is notable in the beautiful traditional clothing of the Cholitas. I shared how uniquely powerful, proud and strong the indigenous people of Bolivia are. There are many native cultures celebrated and respected in the United States but when I learned about them as a young student I always felt like I was learning about the native cultures sadly, in the past tense. The Aymara and Quechua people here seem relevant and current. As I mentioned in my past post in recent years Cholitas have started to change the preconceived notions of the indigenous woman by holding public office positions, working on television shows to promote a different kind of beauty and succeeding in empowering their community through this development.
Another very interesting point that came up in our conversation was the discussion between the importance of preserving culture and the benefit of globalization. This is a very relevant discussion to medicine. On one hand respecting a medicinal remedy that has ancient roots embedded within a culture is incredibly important and on the other bringing life-saving technology into a community that lacks access is without a doubt important. So how can we find a respectful balance between the two? This is how I felt presenting on Osteopathic Medicine to the children’s hospital here in La Paz. It is my hope that someday all healthcare providers will find a way to meld the best of alternative, eastern, western and all types of healthcare perspectives into the one that best serves the patients.
After two days at Hospital de la Mujer, Rachel, Nitin and I spent some time in El Alto to help balance out our health care perspective of La Paz. We awoke early in the morning to meet with Dr. Gutierrez and for the hour trek up to El Alto. Taking two different Telefericos in the cold morning fog gave me so much respect for Dr. Gutierrez and the 18 years she has served through primary care in El Alto. We spent the day seeing patients of all ages and discussed the common health disparities present in this community.
There was one patient in particular whose story I would like to share here. She was a 23-year old presenting for a prenatal appointment pregnant with her fourth child. This patient had undergone three c-sections prior to this pregnancy. Dr. Gutierrez spoke to her about the extreme risk of having another child including uterine rupture among other complications. The patient was devastated at this news. We all spoke of the importance of going to a specific hospital that could care for her in the event that complications with her delivery arose and at that moment the patient called in her husband. Her husband who was 20 years her senior proceeded to speak for the patient for the remainder of the encounter and I was struck by this dynamic. Dr. Gutierrez shared that this woman’s story was very common in El Alto. Many young women get married in their early teens and start having children right away. I was reminded of that our 3 laboring patients in Hospital de la Mujer were all under the age of 18. The line between childhood and women hood feels so thin and I know this is a reality in many places. According to Unicef, the maternal mortality ratio in most recent data (2003) recognized by the Bolivian government was as high as 229 maternal deaths per 100,000 live births. These deaths are mainly due to inadequate care during pregnancy and childbirth as well as a high incidence of adolescent pregnancies. Some 9 per cent of female adolescents between 15 and 18 years are already mothers.
Throughout my time in Pediatric & Adolescent medicine in Bolivia the most prevalent theme that I have observed is how health disparities directly alter health outcomes. From a lack of mosquito nets/education increasing the transmission of leishmaniosis and other vector born infectious diseases to a large prevalence of food disparity causing malnutrition in an increasing population of children under 5, healthcare disparities exist in a multitude of ways within Bolivia. The rights of children, child protection and education in Bolivia are other important healthcare disparities to add to the list. We saw so many patients in the hospital that were admitted for “social reasons” and we learned that most of them were there for child abuse. According to Unicef approximately 80 per cent of children were victims of violent discipline in households and there are many cases of neglect and abandonment. In addition to child abuse one of the first things I noticed when I arrived to La Paz was the incredible number of children I saw on the street selling and working during school hours. A new law was passed in Bolivia in 2014 that allows children as young as 10 to work legally and was met by sharp criticism from many international human rights groups. A 2013 report from the U.S. department of labor reported more than 20% of Bolivians between 7-14 worked. I wanted to share a quote from a child protected by the UNATSBO (Union of Child and Adolescent workers), “Look, we have to work, our families don’t have enough money. We want to give our mothers money so that they can buy food, we want to buy our school supplies … we work, and we’re going to continue to work. So this gives us an opportunity to be recognized and to be more protected as young workers.” But then you’ll talk to other young people who say, “This is not a great situation — our parents need to be able to have better jobs so that they can actually support our families.” The reality of this quote shows me how complicated the really situation is. A child in Bolivia may feel like they have to work and it may benefit their family while affecting their opportunity to get education and exposing them to the street. All of which affect their health outcomes.
I really can’t put into words what this time in Bolivia has taught me, nor how much I have been affected by the kindness and vibrant culture I have experienced here. I leave Bolivia with a deep gratitude for all of the teachers and generous souls who have opened their hearts so widely and shared with me their Andean world.