Rural Medicine in Bolivia...

1. Rural Medicine in Bolivia... • Mauricio Pinto M.D. • PGY-2, Family Medicine • TTUHSC

2. About Bolivia... • Bolivia, landlocked and approximately the combined size of California and Texas has a population of approximately 10 million inhabitants. • Forming its Eastern border by Brazil, western border by Peru and Chile and southern border by Argentina and Paraguay, Bolivia lies in the heart of South America. • Bolivia is Latin America’s most indigenous country, with almost 85% of Bolivian citizen’s of indigenous background.

3. About Bolivia... • Various Indian groups make up this 85% and among them are... • 1. Quechua indians making up 30% • 2. Aymara indians making another 25% • 3. Mestizo. (Indian and Spanish background - 25%) • 4. European (Spanish) descent -15% • 5. other (5%)

4. Bolivia was colonized by the Spanish during the early 1600’s and many descendent’s remain in Bolivia to this date. • Bolivia is also the southern hemisphere’s most indigenously rich country. • Bolivia is also well known for it’s rich geography making it a highly attractive tourist attraction for those interested in extreme eco-adventures. • Mountain climbing... hiking... river rafting... or mountain biking

5. Additional tourist hot spots are the Bolivian amazon, Lake Titicaca, (the highest navigable lake in the world) and the Salar de Uyuni. (the salt flats)

6. Tourists, also come to Bolivia to visit the capital city La Paz, at 12,800 feet above sea level it is the highest capital in the world. Newcomers need to take caution to avoid altitude sickness, one of the most common causes of respiratory complications to those not acclimatized to the high altitude. • Newcomers also can catch sites of llamas and alpacas, animals that live in the highlands and known as the “camel of Bolivia.”

7. There’s plenty to do in Bolivia and it still remains a tourist hot spot despite political and social situations which tend to cause significant problems to date. • Social injustice, low pay, political restrictions, anti-privatization acts and corruption tend to cause social uproar frequently... • Drug- trafficking and drug-related violence is also noted in Bolivia. The coca leaf, which has long been traditionally chewed and brewed by the Indian tribes for centuries, has brought Bolivia to the centerfold of the war against drugs for the last few decades. • Contrary to common belief, the coca leaf has no cocaine in it. Cocaine must be processed through the coca leaf to be produced. Just like paper comes from trees, it needs to be processed to be made, much the same situation.

8. Bolivia has also been put on the international spotlight for the last few years, as the first indigenous president was elected president in 2005. • After years of political corruption, Bolivia had a new change in it’s politics. Evo Morlaes, an advocate for the indigenous population also has proposed a change to the Bolivian politics, strongly aiming at a socialist change. Partnering with other nations with similar goals, much of his campaign was funded by nations like Cuba and Venezuela where these socialist ideals persist.

9. Despite these changes, political and social clashes still exist. Since the 16th century when the Spaniards colonized Bolivia and abolished the indians into a slavery-like class, a stratified society based on have’s and have not’s continues to this day. • Income inequality between the largely impoverished Indians who make up two-thirds of the country and those of European- Spanish descent remains vast and continues to this day. • Also, despite being one of the richest countries in the world amongst natural resources, it remains the second poorest country in South America. It has the second largest gas reservoir in South America, the largest reservoir of lithium in the world, a rich agricultural production, the 4th largest tin producing country and one of the highest potential gold mining industries in the world being hindered by political issues. • Despite these riches, 2/3 of the population live in poverty today.

10. Medical Education in Bolivia... • With approximately 10 medical schools throughout the country, including both public and private schools, medical students must undergo 6-7 years of formal medical training to be eligible for an M.D. equivalent. • To acquire a medical license to exercise medicine from the government, all medical students must also complete 1 year and 3 months of pre-graduate internship. This consists of 3 months of surgery, internal medicine, gynecology, pediatrics and public health. • Those attending Bolivia’s public medical schools are required to do 6 months to a year of rural medicine and those in private schools must do 3 to 6 months of rural medicine. • After obtaining their training and rural requirements, including applying for a medical degree and license, a doctor may take a post-graduate residency in order to acquire a specialty.

11. Rural Medicine in Bolivia... • Bolivia, because of it’s high altitude, rigged landscape, isolated pockets of human settlement, and pervasive ethnological remnants of ancient civilizations has been known as the “Tibet of the America’s” • This unique topography and culture conspire to mark the country for dilemmas in medical care secondary to the ancient cultural medical beliefs that collide with modern day medicine.

12. In rural Bolivia, there is only one doctor for every 7,000 people. Many medical personnel at all levels need more training and universities, although they produce plenty of doctors, 70% of them eventually emigrate to other countries to pursue medical training and professional opportunities. Many communities are without health clinics, and patients often die on long rides in the “back of trucks” as they make long journeys in search of medical care. Even if healthcare is readily available, it can be expensive. • State run hospitals are not equipped with advanced technology and often times are not equipped to deal with medical emergencies. Their resources are scarce and mostly due to poor economic resources towards medical supplies. • On the contrary, private hospitals and clinics are expensive and carry state of the art medical technology as in the United States. This at a much higher cost and unaccessible to the indigenous communities.

13. It is not only physical distance and prohibitive costs that separate rural Bolivians and health practitioners. • Distinct worldviews often cause mistrust between patients and doctors. Doctors and nurses often do not speak Aymara or Quechua, making treatment and medication reconcilliation often times difficult. • The Aymara also view biomedical practitioners, particularly doctors, with great suspicion. Aymara ethnical traditions believe on keeping the body “sealed” and healing through ritual maneuvers. Currently, modern day surgical practices involve invasive “open” surgical practices and often leave the Aymara feeling especially vulnerable and skeptical of their medical care. • Causing more distrust are folk beliefs of the “khasiri” a spirit who was believed to steal the kidneys of the sick during the colonnial period. Concurrent with increasing modernization, the popular and feared “kharisiri” changed to a person, believed to be a doctor, who would sell these “kidney’s” for profit in Bolivia. 6

14. These folk beliefs raise even more suspicion and fear for the indigenous to seek medical care. • Medical care in the larger cities is generally adequate for routine problems, but the quality is highly variable. In rural areas, good medical care may be entirely unobtainable. • Public health services do not reach that far into the countryside. The presence of the “kallawayas” and their medicine provides people with a feasible alternative. • Kallawayas are known as the “naturopathic healers of Inca kings,” and as keepers of science knowledge, including pharmaceutical properties of vegetables, animals and minerals. Most Kallawaya healers understand how to use 300 herbs, while specialists are familiar with 600 herbs. Kallawaya women are often midwives, treating gynecological disorders, and pediatric patients. 7

15. Prior to leaving their homes to heal the sick, the Kallawayas perform a ceremonial dance. The dance and costumary are expressed as the "yatiri", or healer. Groups of musicians, "kantus" play drums and pan flutes during the ritual ceremonies to establish contact with the spirit world before the healer visits patients. 8

16. Bolivians living in rural areas lack proper sanitation and medical services, rendering many helpless against still potent diseases such as malaria and Chagas' disease. Currently, only 20 percent of the rural population in Bolivia have access to safe water and sanitation. • Bolivia's health care system is in the midst of reform, funded in part by international organizations such as the World Bank. The number of physicians practicing in Bolivia has doubled in recent years, to about 130 per 100,000 citizens, a comparable ratio for the region. Current priorities include providing basic health care to more women and children, expanding immunization, and tackling the problems of diarrhea and tuberculosis, which are leading causes of death among children. • Currently, 60% of the country’s population lives in poverty and 37.7% live in extreme poverty. Rural poverty is about 77.3%. 9

17. Tuberculosis in Bolivia • Bolivia has the highest prevalence of tuberculosis in Latin America and the third highest prevalence of tuberculosis in the western hemisphere. • Currently, the prevalence of TB in Bolivia is 170 (per 100,000) with approximately 17,000 patients with active tuberculosis and an incidence of 80 (per 100,000) - smear + cases per year. There are approximatley 8000 patients each year who convert to active TB from latent TB. • Various NGO’s and other international health origanizations take part in the fight against TB in Bolivia including the WHO, USAID and the CDC. • These measures have been helpful but continuing poor access to primary care, poor living conditions of the poor has found it difficult to contain TB and even more difficult to diagnosis new cases as it is believed to be under diagnosed in Bolivia. • A recent article in Bolivia Weekly found that half of prison inmates had active tuberculosis and almost 100% of them tested positive for latent TB. 9

18. Tuberculosis in Bolivia 9

19. Chagas in Bolivia • The bug that spreads the disease (the vector) is called the “vinchuca,” or known as Triatoma Infestans. • The disease is spread by this bug which hides in the leaves of the motacú, which are used to construct many of the roofs in Bolivia. It usually resurfaces while the inhabitants are sleeping. They crawl onto the faces of the inhabitants and defecate on uncovered skin surfaces usually being the face, spreading the disease. • The triatoma bug is usually infected with the disease known as Trypanosoma cruzi. Many people often do not known they are infected until too late when they develop severe dilated cardiomyopathy and autonomic or neuropathic afflictions to the conduction system of the heart leading to disabling or life threatening arrythmias. • Patients often develop megacolon from the loss of tone of the colonic tract secondary to severe neuropathic affection of the colon innervation. 9

20. Chagas in Bolivia 9

21. Rural Bolivia... • Historically, Bolivia has been predominantly rural, with most of its Quechua- and Aymara-speaking peasants living in highland communities.

22. Rural Population in Bolivia • The above graph demonstrates the increasing number of inhabitants into rural areas of Bolivia. The last available data is that approximately 3.4 million Bolivians live in rural areas of Bolivia.

23. Population in largest city in Bolivia • This page includes a chart with historical data for Population in largest city in Bolivia. Population in largest city is the urban population living in the country's largest metropolitan area.

24. Rural population growth (annual %) in Bolivia • This page includes a chart with historical data for Rural population growth (annual %) in Bolivia. The Rural population growth (annual %) in Bolivia was reported at 0.44 in 2008, according to the World Bank. Rural population refers to people living in rural areas as defined by national statistical offices. It is calculated as the difference between total population and urban population.

25. Rural population (% of total population) in Bolivia • This page includes a chart with historical data for Rural population (% of total population) in Bolivia. The Rural population (% of total population) in Bolivia was reported at 34.42 in 2008, according to the World Bank. Rural population refers to people living in rural areas as defined by national statistical offices. It is calculated as the difference between total population and urban population.

26. Rural Rotation… • I completed my rural rotation in Ovejuyo, Bolivia. • Ovejuyo has a population of 1200 with 99% of inhabitants primarily of indigenous background. • I was assigned to Santa Rosa de Lima Medical Post, a busy primary care clinic with many visits daily from Ovejuyo or from neighboring towns. At the clinic we had a nurse practitioner who would ensure we had medical supplies for the medical post • At 11,945 feet above sea level, Ovejuyo also serves as a primary station for enthusiasts interesting in climbing the peak of Illimani mountain.

27. Rural Rotation… • Located approximately 20 kilometers from Bolivia’s capital city of La Paz, Bolivia, the capital city served as a higher level of care center where patients at the post in need of more aggressive care were transported to. • Often times, buses to La Paz did not meet patient schedules so we had to transport them ourselves. • Pregnant women often times did not seek medical care at the post for deliveries. Due to patient beliefs and customs, they asked that their deliveries be attending to at their homes. Most cases did have adequate or any prenatal care and often times their deliveries were complicated due to this. I spent a few days attending home deliveries during my rural rotation and I delivered one baby at the medical post. • We also had one very busy afternoon where a bus heading to an inner town went of a cliff and patients came to the post on trucks or in civilian cars for medical care. 10

28. Rural Rotation… • Most days were not extremely busy and sometimes we had visitors from other nearby medical posts including other medical interns and students. • The medical post was originally a small public school that the government closed and gave to the Bolivian Department of Health for medical care needs. It had a small soccer field in the courtyard and on days without work we would play soccer to stay in shape. • Cable and internet did not exist at the post. 10

29. Rural Rotation… • I spent many days of my rural rotation visiting children at a nearby school to collect data on poor nutrition in the school. • I eventually published a large research study on the prevalence of poor nutrition in the school, a requirement for successful completion of the rural rotation. 11

30. Rural Rotation… • The research study required lots of time and help was needed. Often times, the primary care dental student who was also completing his rural rotation at the clinic would assist me in lectures on proper nutrition at the school and I would assist him in his lectures on proper toothbrushing techniques. 12

31. Rural Rotation… • The rest of the days at the post were spent on patient care. I do recall one patient of ours, a young 3 year old child with severe malnutrition who spent a few days at our post. • Lots of time was spent caring for this child and she quickly became one of the post’s most popular patients especially amongst the nursing staff and visitors with her charming character. 13

32. Rural Rotation… • A massive vaccination campaign also was assigned to our medical post and others. • We spent other days on road trips or hiking up mountains to get to some areas where we could expand vaccination to patient’s not accessible to the post. • Other patients would come into the clinic asking for their vaccines and often made our mission easier. 14

33. Rural Rotation… • Graduation from rural rotation was bitter sweet. Patients who began trusting their physicians had to start over with a new doctor every three months. In general, it served well and granted training physicians a chance to practice medicine for their first time up front and hands-on. It also benefitted patients in rural communities who would otherwise have no access to medical care. • Often times patients had no funding tpo pay for medications so they would bring in items of personal value or offer to pay with livestock. They were appreciated but never taken. • Most patients were grateful for being taken care of and would adhere to their medication regimens quite well. • Bolivia’s today fight against the effects of poverty on health care and often time assist in ways to fight this as possible. 17

34. Rural Rotation… • To this day I recall the memories of my rural rotation and enjoyed every minute of it. • It has helped form my professional medical career and my desire to continue educate myself. • Plans or under way to provide Texas Tech medical students (3rd and 4th year) to pursue a rural rotation in Bolivia through my former medical school. • For those interested please be tuned to this or email to: • mauricio.pinto@ttuhsc.edu 16

35. Texas Tech University Family Medicine Resident Physicians • Top (L to R) Mauricio Pinto M.D., Clint Osborn M.D., Alberto Vargas M.D., Alejandro Miquel M.D., Ikemefuna Okwuwa M.D., Roger Gandionco, M.D., George Abraham M.D. • Bottom (L to R): Abiodun Okin M.D., Debbie Smith M.D., Noor Qureshi M.D., Bita Pour-Jafari M.D., Anna- Marie Francisco M.D., Lulita Ugalino M.D., Daisy Ramirez- Estrada M.D., 16

36. Thank you!!! 16