Learning to Listen

We have begun our last two weeks of working in the hospitals. While I have enjoyed working on this research project, I am ready to head home to enjoy the last bit of summer with my family.

Even though we have been doing these surveys for over six weeks now, I still learn something new every day about both the health care system and people's lives here.

The thing about doing quantitative surveys in place of qualitative surveys is that it becomes very easy to fixate on a certain quota. When you only have to check a box for a patient's response, you start to only become concerned with moving on to the next question. Many times I have found myself getting annoyed when I encounter Chatty Cathys who want to tell me everything about themselves and their mother. If the survey doesn't take less than twenty minutes, I sometimes feel time is being wasted that could be used to survey another patient and add to the total.

While yes, it is important that we try and get a good number of surveys completed while we're in La Paz, I need to remember why I am here. I need to remember why I decided to travel to another country to do my public health internship, one of the poorest countries in South America, nonetheless. I'll tell you what, it wasn't to be a mindless robot and check boxes on a survey.

A conversation that I had with a patient last week reminded me that I need to take time to listen, actually listen, to patients while I am here. This is my education. These conversations are going to propel me into my future public health career. Understanding how health care functions (or doesn't function) and affects people in Bolivia is going to allow me to understand health disparities in the United States and what I can do to help.

When I began the survey with a woman, whom I will call Maria, last week, I quickly found out that she was one of the Chatty Cathys. Each question that I asked warranted a complete story, enough so that I had to repeat the question because she didn't remember what I had asked in the first place. I kept looking at my watch, realizing that this was going to take at least twice as long as it should.

One of the questions on the survey screener is: "Have you given birth to a baby who weighed more than four kilograms?" (Four kilograms is almost nine pounds.) Maria said, "Oh, no, all of my children were around two kilograms." Here's where I come in, making the very ignorant mistake of saying, "Oh, they were small!"

Immediately, Maria began crying. I was shocked. There is a section of the survey that gets at depression, which, actually, comes directly after this four-kilogram baby question. Usually, if the patient is going to cry during the survey, it is during the depression section. Never has asking about heavy babies triggered an unpleasant emotion. The most common reaction I get is women laughing and saying, "Oh, wow, that's a big baby!"

Here I am, sitting with this sobbing woman who is talking very loudly. Because she had very poor vision, she was unable to see that the entire waiting room had gone quiet and was listening to her tell her life story. Although normally I would be very uncomfortable that an entire room of Bolivians was watching me awkwardly console a patient who was breaking down (I am hardly good at comforting people in English, much less in Spanish), a switch went off in me. I realized then that letting Maria unload her burdens was one of the reasons I had come to Bolivia. Who cares how long it takes her to finish this dang survey? I came to learn these stories. I came to listen.

As it turns out, Maria had been very poor while she was pregnant with her children and could not afford to eat very often. She was very skinny and undernourished, and thus, so were her children. She said that the doctors would always yell at her while she was pregnant and tell her to eat, but she was unable to buy any food. When her children were growing up, they didn't even have enough money to buy bread, so they would search in the trash to eat fat off of bones.

I also learned that although Maria and her husband still live together, he has another woman. "What good is a husband for?" Maria asked me. "Only to have babies? They hit you, they yell at you, it's not worth it having a husband."

Maria is currently unable to work because her health is deteriorating. Her feet hurt very much and she is unable to walk well or be on her feet for very long. She lives with her children and three grandchildren, but feels very depressed that she is still, after all these years, unable to provide for her family.

She told me much more about her life, some of which I didn't understand over the sobbing. The worst part for me was that it seemed like this was the first time she was unloading all of these emotions and all of these stories at once. I mean, really, who is she going to tell? She can't really talk to her children about it, and I don't think she can have an effective conversation with her husband about all of these burdens.

While I have been in La Paz, I have been making my way through Paul Farmer's Infections and Inequalities, albeit very slowly. Although our study deals with chronic diseases and Paul Farmer's book discusses infectious diseases, the two are intricately related and both are absolutely related to wealth inequalities. It has been a very good read while spending time in a country with a weak public health system, where I can see daily the effect of such a system on the health of a country's people.

I read this quote after experiencing the emotionally draining conversation with Maria:

"One of the chief benefits of choosing to see illness in global systemic terms is that it encourages physicians (and others concerned to protect or promote health) to make common cause with people who are both poor and sick."

I am here in La Paz to better understand how to "see illness in global systemic terms." Learning stories like Maria's and really listening is, I think, one of the most important pieces of public health training. And, of course, it is an education that should continue throughout one's public health career. Sometimes it is best that I take off my watch and forget about the numbers. In order to know how to serve the people, how to "make common cause" with them, I need to remember to keep my ears wide open.

Hospital Bathrooms and Other Public Health Beefs

We have now been working for six weeks doing surveys in the hospitals in La Paz. We've cut our survey times down in half, we're now [EXCITINGLY] enrolling patients in our automated voice response system to help them control their diabetes and/or hypertension, and we've become friendly with doctors, nurses, and patients along the way.

While we've had several engaging conversations with many of the patients and overall have had a positive experience working in the hospitals, all of this time spent in the waiting room has allowed us to see the many flaws of the health care system here. I've built in my head a list of all the things that have frustrated me the most about public health in the hospitals here, so I just need to get it all out.

Appointment Issues

• People leave appointments with prescriptions, treatment plans, and lab results and have no idea what they mean. Countless times patients have come up to me saying, "Doctorita, can you tell me what this means?" It breaks my heart that after their consultation with the doctor they are left with more questions than when they went in.
• One very sick patient and their family members were waiting for a long time to see the doctor. Eventually they went up between appointments and asked if the doctor could finally see her now, and the doctor said no. The patients in the waiting room heard this confrontation and had a fit; everyone started yelling, "Doctor, you need to attend to your patients! You need to take time to see everyone!" Patients shouldn't have to be telling their doctors that they need to care, even just a little bit.
• Patients start lining up at the hospital at 4:30am to hopefully get an appointment with their doctor. However, sometimes the doctor doesn't even come in that day and no one tells them, or the doctor runs out of time and they don't get an appointment after all. Even after lining up and purchasing a ficha to see the doctor, they have no idea when they could be called.
• After purchasing a ficha and waiting several hours, the nurse or doctor will finally call a patient's name. If the patient doesn't make it to the door by the second time their name is called, they have to wait until all the other patients are called.

Accessibility

• Today I saw a man carrying his mother in her wheelchair up the stairs in the hospital because there is no public elevator. While La Paz itself is not handicap-accessible, you would think that at least the hospital would be.

Doctor-Patient Relations

• Doctors and nurses commonly talk about patients right in front of them as if they don't exist. 
• Doctors and nurses also violate HIPAA privacy rules, such as talking about specific patients' personal information, with other people in the waiting room (and not quietly).
• There is no barrier between the waiting room and the doctors' offices. Patients commonly knock on the office door while other patients are having a consultation, begging to be seen. 
• A doctor has asked us if we could please contact a surgeon in the United States who could do a special surgery on one of his patients. Oh, and if we could figure out a way to get her there, please and thank you.

Blood Pressure Monitor Issues

• We give out blood pressure monitors to hypertensive patients enrolled in our system. Diabetic patients receive a first aid kit, which is still a cool gift, but definitely not as valuable as a blood pressure monitor. We have had some problems with this value discrepancy, with many people who don't have hypertension wanting the blood pressure monitors. Not really a health care problem, but frustrating for us, nonetheless.
• Oh, and we have the best-functioning blood pressure monitors in the hospital. So much so that the doctors and nurses ask us to measure their blood pressures.

Sanitation

• There is no fully functioning bathroom in the hospital. There is one bathroom that patients are told to use, located in the emergency department. There is no toilet seat, no toilet paper, and a sink with no sign of any faucet or water hook-up. And I don't even need to mention that there is no soap or hand sanitizer to be found anywhere. Several times I have entered the bathroom and the sink is full of blood. I hate thinking about the fact that this is the one bathroom that all the patients are using, and I doubt most of them carry their own bottle of Purell.
• Dogs frequently walk in and out of the hospital, sometimes all the way up to the waiting room on the second floor where we do our surveys. No one seems to blink an eye or try to shoo the dogs out.

Obviously I am not an expert on the Bolivian health care system or the way that any other hospitals here are run, but I would guess that many public Bolivian hospitals are similar to the one I am working in now. I will also say that being an outsider, just as in any situation, it is definitely easier for me to pick out the flaws in the system than realize the good in it. But it has become very easy to understand why it is difficult to control a chronic disease in a poor country such as Bolivia when the health care system is so inefficient and difficult to navigate. I would imagine that impoverished regions of the United States experience similar issues as the ones I am seeing here, over 4,000 miles away. It would be interesting to compare and contrast these systems and see if the health outcomes are the same.

Also... three weeks until I am home!

The World is a Strange Place

There are certain moments in your life when you realize that you really don't know very much about the world. Certain times in which what you expect from a place is completely put to rest. Never have I experienced so many different landscapes in such a short amount of time as this past weekend.

As today is a holiday in La Paz, we decided to take Monday off and make a long weekend trip. We left on Friday night and took a 12-hour bus ride to Uyuni. From Uyuni we hopped in a jeep with a tour guide and did a 3-day, 2-night tour of Salar de Uyuni.

I had known that the tour of Salar de Uyuni would include the largest salt flats in the world, but I was pleasantly surprised with everything else the tour included.

Day One

First we were whisked off to the train cemetery. The trains used to be used to carry minerals from the salt flats but were abandoned around the 1940s. Now it is basically a giant playground for tourists.

We then ventured off into the big bad world of the salt flats. I had previously been to the salt flats in Argentina, and I was a little unsure that I wanted to do the salt flat thing again. However, these salt flats are almost twice as big, and once we were there I was definitely not disappointed. We also enjoyed a delicious lunch of quinoa, llama steak, and veggies while sitting on the salt flats.

We began driving again, seemingly off into nowhere. Suddenly, we came across an island of cacti called Incahuasi. It makes sense that there would be islands since the salt flats were originally prehistoric lakes, but I was not expecting it at all.

After Incahuasi, we drove off toward the location where we would stay the first night, stopping once more on the salt flats to enjoy the sunset.

The first night we stayed in a hostel made of salt. The floor, bricks, beds, tables, and chandeliers were all made of salt. It was so cool!

Day Two

We left early in the morning to head out toward our destinations for the day. First we hit up a series of cool lagunas. What really blew my mind were the lakes filled with flamingos. Never in my life did I picture flamingos living in an ice-covered lake in Bolivia.

We also spent a good amount of time playing on rock formations. It was the strangest thing: we would drive for about 45 minutes listening to 90s techno music, and then our driver, Ronald, would say, "Ok, you have 15 minutes here." We were always absolutely amazed with where we had ended up.

The second night was the coldest I had ever been in my entire life, but it was absolutely worth it. The hostel was located at least 15,000 feet above sea level, and our tour guide said the temperature gets to -25 degrees Celsius at night.

Our hostel had electricity from 7-9pm, which was fine because we had to wake up at 4:30am to be on our way in the morning. I slept in a sleeping bag underneath blankets in layers upon layers of clothes, gloves and a hat, and my toes were still freezing. But we woke up in the morning to tea, pancakes with dulce de leche, and yogurt with granola, so even though my body hated me my belly was happy.

Day Three

In the morning we stepped outside the hostel and there were more stars than I had ever seen. It made me feel so small, and it was so strange to think that if anyone had wanted to contact me during the weekend, there would be no way to contact me.

We made it to the geysers before sunrise. I had never seen geysers before, and I still don't really understand how they work. Even though my toes were freezing, walking around the geysers while the sun came up was soooo cool. It felt like we were on another planet.

After the geysers we drove around some more until we were at the border of Argentina, Chile, and Bolivia. Located at those borders is the Laguna Verde which really isn't verde anymore, but it was still awesome to think about where we were in the world.

Next we took a dip in some thermal springs, which finally warmed up our toes. It was amazing to be soaking in hot water and surrounded by steam and snow-covered mountains.

The rest of the third day was mostly spent driving back to Uyuni, where we were to catch our bus back to La Paz. We had a lot of ground to make up since we had been driving south for the past two days, but the amazing scenery made the long drive worth it.

We had the company of some sun-saluting llamas where we stopped for lunch.

We also came across some more awesome rock formations, which we climbed all over, of course.

The last hour and a half back to Uyuni definitely dragged on. We were tired, smelly (we hadn't showered or changed clothes in three days) and not really looking forward to the 12-hour bus ride ahead of us. But even while my toes were frozen and my nose was filled with dust, everything about our trip to Salar de Uyuni exceeded all of my expectations. I can't believe I have less than a month left in Bolivia. While I am ready to be back home, this trip has definitely left me recharged for the few weeks left we have here. Most importantly, traveling to this region has left me with more questions and curiosity about the world and the many strange places in it.

Beware the Cold

I'm not sure that I've mentioned that it's cold here. Really cold.

It's no colder than Michigan in the fall, in reality. During the day it's about 57 degrees, and in the sun, it's pretty comfortable. At night, temperatures fall to about 30 degrees. Coming from Michigan, we should be totally used to this, right? The problem is that in Bolivia, there is no indoor heating, and very very few families use space heaters because the electricity is so expensive.

You would think that people who live in La Paz, where the climate pretty much stays the same the entire year, would be used to living in the cold. However, talking about the cold is one of the main conversation topics that I have with strangers.

Talking to the woman at the front desk of the gym:
Me: Hi! How's it going today?
Woman: Ahh, it's so cold today!

Running into someone in the elevator of my building:
Me: Good afternoon! How are you?
Person: Fine, but it's so cold!

Interviewing someone at the hospital:
Me: Wow, you are really wearing a lot of coats today! (They have to take them off for their blood pressure, weight, etc.)
Person: Yeah, it's so cold today!

During a Pilates class:
Instructor: You ladies need to make sure to wear two layers of socks next time. The floor is cold. You're going to get sick.

Measuring someone's blood pressure:
Woman: Ah! Your hands are cold! You need to wear a coat. You're going to get sick.
After the interview -- Make sure you put a coat on!

Leaving the gym:
Person: Where's your scarf? You need to cover up!
Me: Thanks, have a good night!

The cold permeates every aspect of people's lives here. For this reason, there are some rules you must follow to make sure you don't get sick:

• Don't take a shower at night or in the morning. It will make your belly cold and you will get sick. Always shower in the afternoon.
• Don't walk around with just socks on. Always shoes. The cold will come in through your big toe and make you sick.
• Don't eat lettuce when it's cold. The cold will go into your belly and make you sick.
• Don't drink cold Coca-Cola when you're sick. It will make your throat cold and you will stay sick.

When we do get sick, with a cold or diarrhea or what have you, it is definitely our fault. We forgot one of the rules for avoiding the cold, and for that reason, we got sick. Sometimes it's hard to remember all the rules to follow to keep the cold at bay, but the people here are nice enough to remind us of them.

Oh, Bolivia.

Gay Pride in La Paz

I will never forget the time that we ended up in a gay pride parade in La Paz.

Through a Bolivian friend, we knew that the parade was going to happen, and we were super excited to attend. Saturday night, 7pm. Ok, we'll be there.

When we met up with this friend, we quickly realized that WE were going to be in the parade. We were given different colored t-shirts and were thrown on the back of a parade float that was decorated with a rainbow of balloons. I was leaning on the speaker, trying not to fall off the back of the truck, and the bass vibrated through my body as we toured through the streets of La Paz on our way to the Prado, the main street.

We made it to the Prado and all got off the float. When the other floats met up with us, we were all given flags and pom-pons and the music started and we were off! We danced down the Prado, and thousands of people gathered along the street to watch.

I was afraid that we were going to meet a lot of hecklers and protesters, but we didn't see any! The coolest thing was seeing the cholitas and the little children smiling and waving their rainbow flags. I was so impressed to see the support from the people in La Paz. I had thought this whole time that no one in La Paz really supported or respected LGBT individuals. This really changed my mind about the people here. Of course, the gay community is still kept under wraps, and it is really difficult to be gay here, as in many places in Latin America. But this event showed me that there is hope for the future in La Paz. I was so proud to be a part of this event. I never thought this was going to be part of my experience while working here. It was definitely one of my favorite nights so far.

Warming the Bones

There's nothing like a blast of hot humidity after living under layers of clothing and fighting dry skin and bloody noses. I tried to save up all the humidity I could in my pocket to remember during the coldest nights that at one time, my body did feel warm.

Coroico is a town in Los Yungas, an area of Amazon lowlands within the department of La Paz. Many Paceñas (people living in La Paz) travel to Los Yungas during feriados (holidays), and some even have houses in Los Yungas that they travel to on the weekend. I completely understood why once we arrived. Los Yungas are only a 2-hour trip away from La Paz but are like a completely different world. From La Cumbre, the highest point of the trip, to Coroico is about 67km and a 12,000 foot drop in elevation. The journey is unbelievable. You go from snow-capped mountains to jungle plants (and mosquitoes) within two hours.

We went to Coroico as a whole group, minus one of our team members. Even our director joined us, although he had to make a return trip that same day because he was flying back to the States in the morning. The mom and brother of one of our team members were visiting, and they made the trip there and back in one day as well. The rest of us stayed the weekend in the jungle.
When we arrived in Coroico, we went to this German restaurant called Back Stube that was recommended in my Rough Guide: Bolivia book (thanks, Dad!). I got sauerbraten, which I realize is a strange thing to eat in the jungle, but it was really good!





The first day, we also went to a waterfall that was a little outside the city. The boys decided to swim under the waterfall, and the rest of us watched. The Bolivians really enjoyed watching them swim and took a lot of pictures of them. I'm not sure waterfall swimming is a very common thing to do during this time of year. The water was pretty cold!


We had a pretty enjoyable time trying to get back to the city. There weren't very many buses going back to Coroico, and it was dark before we caught a bus. There was only one road leading back to town, so we would have been fine. Luckily, though, a bus eventually came with enough room for the nine of us.

On Saturday, we took an amazing hike down a valley to a river where there are some good swimming spots. I got a good number of mosquito bites on the way down, but it was totally worth it. The further down into the valley we got, the hotter and more humid it became. We were actually sweating! The views were amazing on the way down, and the river at the bottom of our trek was a sweet, sweet ending.

We spent most of the day at the river, eating tuna fish sandwiches we had brought along and enjoying the sunshine. There were a good number of families down at the river as well, and one family shared their mandarins with us and taught us how to fling the peels like frisbees.

The girls at the river

We ended up having dinner at the same pizza place two nights in a row. It was run by a French woman, and her dishes were amazing! We shared a four-cheese pizza one night, and the second night, we shared the same pizza and each got individual pasta dishes to try. I got the homemade pesto gnocchi. It was absolutely delicious. Again, another weird thing to eat while in the jungle, but it was good!

On Saturday night, the town of Coroico went crazy! Sunday night in Bolivia is San Juan, the shortest and coldest night of the year. In the plaza, firecrackers were going off all night long. There was a clown that was putting on a show for the children, and at the same time, a movie was being shown and a folkloric band was playing. It was definitely sensory overload, but it didn't seem to faze any of the Bolivians that were there. We tried going to bed a little early, which was a joke. The entire town was having a party!

The plaza in Coroico

View while eating breakfast

On our final day in Coroico, we took it easy. Ate breakfast, walked around the market a little bit, collected our things at the hostel. We made it down to the bus station by noon, but by that time all the buses to La Paz were booked until 3pm. All the Paceñas were making their way back home after the holiday weekend. So, much to our dismay, we had to enjoy the wonderful views and warmth for a few more hours.

I feel refreshed and recharged after our weekend in the jungle. I brought back with me some mosquito bites, a sun-burnt nose, and some hope that my body will again see sunshine. For now, I will use the memories from this wonderful weekend to propel me through the working weeks to come.