My time in Bolivia

Jocelyn S. Chapman, a second-year student at the School of Medicine, spent eight weeks this summer conducting research in Bolivia on antibiotic resistance, with a fellowship funded by the Miller Family Foundation. Her work included shadowing doctors at Hospital del Nino, a 160-bed pediatrics center in La Paz, the nation’s capital. At the hospital Chapman became close to two doctors, who shared with her their candid thoughts about the challenges of treating the children of poor, uneducated families. She wrote about her trip for BU Today.

La Paz, Bolivia, is a huge city with a modern skyline and a population of more than two million people. For all La Paz’s apparent modernity, its streets are full of countless abandoned and orphaned children. There are almost no social programs to provide homes for them.

I recently returned from the city, where I spent time at the Hospital del Nino, a national pediatrics center that offers free care. With an annual budget of about four million bolivianos, or approximately $500,000, it is desperately underfinanced, with broken-down facilities, few supplies and medications, and poor sanitary conditions. And doctors face other challenges: the poor education of their patients’ parents and family members and cultural differences that make communication difficult.

“One of the things I find most frustrating is the lack of parental understanding about their child’s health care,” says pediatrician Alberto Duran. He has worked at Hospital del Nino since 1987 and always has a kind smile for the children he sees at the hospital, but he often delivers stern lectures to parents. “Multiresistant tuberculosis is a big problem in La Paz,” he says, “because so many parents don’t finish the treatment once their children leave the hospital.”

At Hospital del Nino, children who are diagnosed with tuberculosis typically stay for two months of drug treatment and then are discharged to continue six months of drug treatment at home. Duran estimates that 5 to 6 percent of children never finish the tuberculosis treatment once away from the watchful care of doctors. “I wouldn’t be surprised if the failure rate were higher,” he says.

While they appear healthy, children who haven’t fully completed treatment harbor inactive but alive tuberculosis bacteria and can become sick again when their immune system is weakened by illness or malnutrition. Furthermore, tuberculosis bacteria that have been exposed to, but not eradicated by, antibiotics develop defenses against the drugs and become resistant. It is the resistant strains of tuberculosis that are of course the most dangerous — there is no way to treat them effectively without developing new drugs.

By comparison, the United States aims for a zero percent treatment failure rate. U.S. public health officials are charged with making sure tuberculosis patients receive and take their medication for the duration of treatment using the directly observed therapy (DOT) program. Patients in the DOT program meet with their health-care worker to take their medicine under the health official’s watchful eye.

This kind of government support does not exist in La Paz, resulting in a high rate of failed treatment and emergence of the more dangerous drug-resistant strains that physicians in La Paz are seeing with alarming frequency.

Alfredo Mendoza has worked at Hospital del Nino since 2000. Medical residents are in awe of the gregarious physician’s diagnostic skills. Like Duran, who has a private practice with paying patients to supplement his $500 monthly salary at the hospital, Mendoza is frustrated by the lack of parental education about child health issues such as nutrition, sanitation, and drug treatment. And since many of their patients are from indigenous families who often speak local dialects and have little or no Spanish, doctors at Hospital del Nino also confront social, cultural, and language barriers. With their busy schedules and lines of waiting patients, the doctors struggle to make clear the importance of following instructions, even resorting to paternalistic verbal scolding of parents they feel are being noncompliant.

Both Mendoza and Duran are fathers of identical twins. Asked if he would bring his sick child to Hospital del Nino for treatment, Duran responds without hesitation: “I trust the physicians here. They are well educated, and they offer the best care available to children in the city.” Mendoza, on the other hand, says, “I would prefer to have my child treated at a hospital with more modern facilities, equipment, and access to advanced diagnostic tests.”

Political instability

I arrived in La Paz in mid-June, a week after demonstrations against the continued presidency of Carlos Mesa brought about his resignation. The former president is only one in a long line of presidents whose terms have been cut short by protests; Bolivia has had five presidents in the past six years.

The most recent unrest is attributed to failure to deliver on the promise of nationalizing the oil industry. But tensions run deeper. The indigenous majority has been chafing for years at not having more say in the government and is demanding that the constitution be rewritten. The prosperous eastern city of Santa Cruz is responsible for 35 percent of Bolivia’s economic output but accounts for only a quarter of Bolivia’s population. The people of Santa Cruz want autonomy.

This unrest was in the forefront of the minds of the Bolivians I encountered. With elections upcoming in December 2005, Mendoza and Duran have clear ideas about changes to child care they would like to see.

Mendoza believes that current social and health-care policy “places the greatest burden on our children, our county’s future and our most vulnerable population. They are bearing the greatest weight, and we cannot allow this to continue. If we do, we put the future of our country in jeopardy.”

Duran agrees and offers these solutions: “Health care for all children should be free and accessible. Right now, only the wealthiest families can afford health care. Access is a real problem, and while the free care at Hospital del Nino is a step in the right direction, we need more physicians, more nurses, bigger facilities, and more technology.”

Like any developing country, the issues facing Bolivia are complex and have no simple solutions. Mendoza and Duran agree that throwing money at the problem without well-trained physicians to make good use of the funds will not bring the country closer to a solution. The two physicians are tireless caregivers for the children of La Paz, but they can’t do it alone.