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.

The Waiting Room

Something bad happened last Thursday. This event made me realize a lot about the Bolivian health care system, or at least the hospital in which I am currently working. It also made me realize that I have the responsibility to care for the patients with whom I am interviewing on a different level. I need to make sure that I fully understand their stories and that I really listen.

Here is our system of interviewing patients:

1.     Arrive at 7:45-8:00am to get situated with our surveys in the waiting room and bring out the balance to measure patients

2.     Randomly choose patients in the waiting room to interview

a.     Measure blood pressure, weight and height during the screener

b.     Continue with the survey if patients are eligible

3.     Randomly choose another patient to interview

4.     Continue until about 1:00pm, when the waiting room is empty

This is where the problem comes in. Patients arrive at the hospital around 5:30-6:00am to get in line to try and get an appointment with the doctor. Patients receive a number, but this number does not tell them what time their appointment is going to be. I frequently encounter patients who have been waiting for 5 or 6 hours to see the doctor. When the nurse steps out of the office and calls someone’s name, the patients literally sprint to the door, including older men and women and mothers carrying their babies. If they call your name and you don’t make it to the door before they call someone else’s name, there’s a good chance you’re out of luck to see the doctor that day.

I caused someone to miss their appointment on Thursday.

I was in the middle of measuring a patient’s blood pressure when the nurse stepped out and called her name. She frantically stood up and waved her arms and said, “That’s me! I’m coming! Wait for me! I’m here!” We tried to very quickly undo the Velcro of the blood pressure cuff. By the time the patient had collected her things and sprinted to the door, it was too late. The nurse said something to the patient and I could tell she was pleading with her, but the door was shut in her face. She sulked back to me, crying. I was devastated. “I missed my appointment,” she told me. “I have to wait until all of the patients have seen the doctor today before he will see me.”

This patient had arrived at the hospital at 5:30am. It was now 11:30am. Six hours of waiting, and now she had to wait even longer. To make matters worse, she was seeing the doctor to receive lab results from the previous week to find out if she had diabetes.

I apologized to her a million times and told her we didn’t need to continue with the survey, but she got her tissues out of her purse and said, “Please don’t worry, this always happens here. People always miss their appointments because they call your name but don’t wait for you. This always happens. I want to continue with the survey.”

So, we continued with the survey. Luckily, right when we finished, the doctor called her in. I was glad to have been able to occupy her while she waited even longer to receive her results, but I still felt like the worst person in the world. After she came out of her appointment, I apologized to her again. She told me she was just diagnosed with type 2 diabetes. By this time, the waiting room had cleared out, so we were done with surveys for the day. Even if the room was full, though, I was so drained that I wouldn’t have been able to enter another patient’s world.

I can’t imagine having to wait for 6 hours to receive care, and then after those 6 hours, maybe not being called in to the appointment at all. Who has that much time to take off of work or to be away from their children? What if during those 6 hours you had to use the restroom, which is very likely, and they called your name?

Many people I have interviewed have said that this is the first time they are seeing the doctor, and now I understand why. Who has the time or energy to manipulate such a system? Of course people are going to wait until there is something urgent to see the doctor. Preventive health care and regular doctor visits are just too much of a hassle.

Being in the waiting room for five hours, not even the amount of time that many of the patients are there, and interviewing patients has been such an eye-opening experience. I have been trying to really pay attention to what patients are telling me outside of the A, B, C, D answers on our survey, because their stories are so rich. Everything they tell me between survey questions leads me to a better understanding of how health care can be improved in Bolivia and in the United States.

I hope this experience never happens again, but I’m sure that it will, especially considering that this was our first full week of doing surveys. I think the best that I can do is to save these stories and experiences, share them, and hope that maybe in the future, health care access can be improved for those who need it the most.

Fighting Cholitas

One of the strangest things I've seen in my entire life. Lucha libre, Bolivian-style.
Not much more to say about that.

We were able to go to the bathroom TWICE. What a deal.

The view of the city afterwards was really pretty.

Learning As I Go

Choosing to do an internship in another country is not an easy decision. First, you have to make sure you find a grant that will support your research endeavors. Then, you have to weigh the cost of possibly not being as productive or getting as far in your research as you would like due to the infrastructure of the country. Doing a domestic internship definitely doesn't guarantee that your research will go as planned, but it's easier to adjust if something goes wrong. You also have to think about how an international internship is going to help you accomplish your future goals. It may sound exciting to be abroad for a summer, but will it help in the long run? Finally, it's important to think about the summer that you may be missing out on by being abroad and the opportunities that may lie back home.

After being in Bolivia for a month, I can safely say that I made the right decision by choosing to go abroad for my summer internship. Yes, it has been difficult starting a research project in Bolivia. Communication among institutions is not as smooth or efficient as we would sometimes like, and the process of starting up takes much longer. This past month, we have been attending numerous meetings, explaining the basis of our research project to many different groups of people, from the hospitals to the universities, trying to get everyone on board. Many people were surprised at how young we were and seemed a little wary that we weren't medical students. However, after the arrival of our project director, people started taking our group more seriously and the project picked up.

This week, our group of ten was split up into five groups of one med student and one public health student. Each group was assigned to a different hospital. Each group is going to stay at their assigned locations for a little while, so the doctors and staff are used to seeing us in there. My partner and I were able to tour our location, Hospital La Paz, yesterday. The hospital is about 50 years old, and it, like many of the hospitals here, is lacking in some essential resources. For example, the doctors urged us to bring our own blood pressure monitors because the ones at the hospital leak air and don't give an accurate reading. But all of the doctors that we met at the hospital are very friendly and are excited for us to begin interviewing patients there. The main doctor that we are going to be working under has his own medical TV show on Mondays, Wednesdays, and Fridays, and he wants us to go to the station with him one day to watch.

We were able to complete some surveys at Hospital Holandes, a hospital in El Alto, earlier in the week. This hospital serves a very poor population and seems to have a very strong political bent. When we walked into the office of the head doctor, we were greeted with side-by-side posters of Chavez, Che, and Morales and Bolivian and indigenous flags.

My first experiences with these interviews at Hospital Holandes is one of the main reasons why I know I made the right decision to do my internship abroad. At first, I wasn't exactly sure how working abroad would be different from studying abroad. Within the past month, I have found that working abroad gives you the ability to access many more institutions and people and to have a much better idea of how a country is run and how people live their lives than studying abroad. I think this is especially true for a public health internship. Your health affects the way that you go about your daily life, and your daily life affects your health. The two go hand-in-hand. Many of the questions on our survey get at activities of daily living, and it is not uncommon for participants to begin to tell us stories of their jobs and family life. Through listening to these stories, I am beginning to see trends in how daily life here can affect one's health. Here are some stories of the people I have talked with:

• An older cholita attending the hospital to help her young daughter with a check-up for her baby. She didn't have time to finish the survey because they had to get the baby back home. She was very distracted throughout the interview and said the health of her young daughter was not very good.
• A 19-year-old woman who was recently diagnosed with gestational diabetes. She was attending the clinic alone and was very worried about what the diabetes meant for her baby's health.
• A 19-year-old woman who was attending the hospital for a check-up for her 6-week-old baby. She was overweight and was trying to lose weight to improve her health.
• An older cholita who worked from 8am-11pm seven days a week as a vendor at the market and a housekeeper. She had never been to the doctor before and had all of her children at home. She was overweight and came in to the hospital for chronic knee pain because she was unable to work to support her family.
• An older man who spoke Aymara and a little bit of Spanish. He was very difficult to understand but was insistent on getting his blood pressure taken. I found that he had very high blood pressure and this worried him very much. I gave him a slip of paper with his blood pressure written on it, but due to the language barrier, was unable to calm him.
• A middle-aged cholita who had traveled a great distance from the countryside with her baby. She had diarrhea and kept mentioning this throughout the interview.

We have also been noticing that there seems to be a lot of undiagnosed depression here. There are a few depression questions on the survey and sometimes it seems that this is the first time anyone has asked them how they feel. For example, one of the questions is, "During the past week, have you had little interest in doing things?" or "During the past week, have you slept more than usual or had less of an appetite?" Many times, people say, "Yeah, actually, I have felt that way. More than half of the week I've felt that way." Now, it is hard to tell if this is actually depression or if people are overworked and tired, but it is not uncommon for people to answer the depression questions this way.

Starting on Monday, I will be officially starting with surveys at Hospital La Paz. I am excited to have an established work schedule and to continue having conversations with people about their health and daily life. These conversations have given me so much more of an insight into how not only how people live their life, but how the country is run. This understanding of the relationships between work, family, government infrastructure and health is definitely going to help me to establish and understand these connections no matter where I end up working in the future.

On Wednesday night, our group had the opportunity to attend a fundraiser for Arco Iris, a children's hospital in La Paz. This event was held at the Radisson Hotel and was much fancier than I imagined. There were some of the wealthiest people in Bolivia in attendance, including the ex-mayor of La Paz and a couple of future presidential candidates. In fact, the emcees of the event were a prospective presidential candidate and a woman who has a morning TV show. There were also some representatives from HOPEnetwork and USAID. The event consisted of children playing instruments and singing, a video about the hospital and its impact on the children, and a raffle. The prizes from the raffle were things such as an iron, towels, and a printer. Everyone who "won" gave the "prizes" back to the children.

Because the event was called "The Banquet of Crumbs," the food consisted of platters of cheese, ham, grapes, nuts, and lots of bread that the waiters kept bringing out. There was an endless supply of cheese. As the event was about 3 hours long, we were all pretty unsure about how much cheese we actually consumed. We had a good time networking with other professionals in the health field, and I think Arco Iris raised a lot of funds.

We have had the opportunity to meet so many important and interesting people in the health field in Bolivia, such as the head epidemiologist at SEDES (Service Department of the Health of La Paz) or the head internal medicine doctor at Hospital de Clínicas, who is also the president of the Bolivian Association of Atherosclerosis. Each doctor and professor we have met has had a different idea about how the government helps or hinders health. I am so grateful to have had this kind of access while working in Bolivia. These connections have given me such a better idea of the potential our intervention can have on the health of people here.

Copacabana

Many exciting things have been happening since my last blog post. Our project directors arrived and we have been having several meetings with the hospitals and important health professionals in La Paz and El Alto. I'll keep you updated on our work soon!

The med students (there are five of them) also arrived this past Thursday, and we have been having a lot of fun with them. This past weekend, our research group (minus one and plus a student's brother) took a trip to Copacabana, which is on Lake Titicaca. The city is about 3 hours away from La Paz by bus. At one point you have to take a ferry across a stretch of water and then get back on the bus to continue to Copacabana. The buses are ferried across on rafts made of 2x4s that look like they're about to sink.

When we got to Copacabana, we found a hostel for 20 Bolivianos a night (about $3). We then found the perfect place to eat lunch: a restaurant with outdoor seating, plenty of sunshine, and trout any way you like. We were in heaven.

In the afternoon, we climbed Mount Calvario, one of the hills bordering Copacabana. The views at the top were amazing. We watched the sunset listening to the languages of people from all over the world.

On our second day at Lake Titicaca, we decided to take a boat to Isla del Sol. It was about a 2-hour ride to the island, and it rained for part of the trip. On the island, a guide took us to a museum and then on a hike to some ruins. We then took about a 3-hour trek across the island to catch our boat on the other side.

I knew that I wanted to see Lake Titicaca while I was in Bolivia, but other than that I didn't have many expectations for this trip. Everything seemed to work out just perfectly, from our decisions on where to eat to our trek across Isla del Sol, and I was pleasantly surprised with how beautiful the views were. Below is a chronicle of our amazing weekend.

Day One

Going across the stretch of water on our way to Copacabana.

The view of Copacabana from the bus.

Basilica of Our Lady of Copacabana

Another memorial for Eduardo Abaroa, a hero in the War of the Pacific, when Bolivia lost their access to the sea.

Mount Calvario in the background. We climbed it in the afternoon.

You can order trout any way you like!

Beginning our trek up Mount Calvario.

On the way to the top of Mount Calvario, there are ten of these stations. People bring up ten rocks with them and place them at each of these stations to represent their sins.

View of Copacabana from Mount Calvario 

Watching the sunset at the largest lake in South America.

Day Two

In the morning, we ate at what has been my favorite breakfast joint in Bolivia so far. It was called El Condor & The Eagle, and was run by an Irishman. He made delicious oatmeal, soda bread, and french press coffee. 

We started our journey to Isla del Sol (Island of the Sun) early in the morning. It definitely didn't look very sunny. 

But when we arrived, the island lived up to its name.

Ruins on Isla del Sol dating to the Inca period. According to the Incan religion, the sun god was born on this island.

Ruins on Isla del Sol

On our trek across Isla del Sol. The views were absolutely amazing. 

Someone's house on Isla del Sol. There are about 800 families that live on the island. I kept having to remind myself that people actually live there, and that they have those views everyday. On the flip side, though, life on the island is very hard, and people there don't have access to many resources.