Archive for the health care Category

26 de Septiembre: Hasta en las ciudades…

Posted in Bolivia, health care with tags , , , , , , , , , , , on September 26, 2010 by eugeniadealtura

Earlier this week, the UK’s Guardian released a video chronicling the efforts of UNICEF representatives and their local allies to improve sanitation and access to clean water in Bolivia’s rural communities.  The video features interviews with Bolivian community members about the frequency of child death due to diarrhea and describes recent latrine construction projects in what looks like the country’s temperate and tropical regions in the east.  Sanitation projects in the area are being undertaken by UNICEF in an effort to speed progress on the UN’s “Millennium Development Goal” 7: to decrease the population lacking access to clean water and sanitation services by half by 2015 (the MDGs were established in 2001).

The infamous “camino de la muerte,” on which this truck is driving, carries travelers between La Paz and rural communities in the Yungas.

The state of sanitation services in Bolivia is undoubtedly the worst in rural areas, where lack of running water and sewer systems make illness frequent, even for the most dedicated of hand-washers.  If UNICEF truly wants to speed progress on MDG 7 in Bolivia, however, it would be wise to install potable water in city taps, and to support hand washing in cities, as well as rural areas.

In La Paz and El Alto, the majority of Bolivians buy their produce and other food stuffs in busy outdoor markets lacking adequate bathroom facilities.  Vendors and customers have to pay .50Bs to visit public toilets where, even if there is running water, soap is rare.  Market-goers then handle produce, passing whatever bichos they may have acquired at toilets on to consumers back at home. While it is standard practice in these cities to wash fruits and veggies before eating them, most use tap water to do so–a water that is so contaminated that it often emerges from the tap smelling of sewage.

This health care facility sits right above a public market.  The fact that hand washing is rare in both arenas provides ample opportunity to spread communicable disease.

Even more distressing, many hospitals and clinics in La Paz and El Alto fail to provide adequate sanitation services to patients and their families.  Over the past couple of years, my work has taken me for several hours each week to both public and private medical facilities in La Paz and El Alto. At the public hospitals I visited, neither public nor staff bathrooms provided toilet paper or soap to users. This means that not only patients’ families, but likely medical personnel had a hand in passing illness on to patients with vulnerable immune systems.  At one private clinic I visited in El Alto, three pans of blood and human tissue lay on the floor in the corner of the bathroom, ostensibly standing in for legitimate biohazard containers.  I was lucky to not have tripped over them and spilled them on the way to the toilet.

Poor hygienic conditions in Bolivia have often been explained in racist terms by policy makers and other professionals who pointed the finger at the country’s “dirty Indians” as vectors of disease transmission.  Arguments that indigenous populations were “naturally filthy” or resistant to personal hygiene were often promoted by western doctors attempting to push indigenous midwives and traditional medicine practitioners from the country’s health care scene.

The above observations, however, reveal a different truth: Bolivia’s western, state-run hospitals lack proper sanitation infrastructure.  Doctors, nurses, and patients alike are denied the tools they need to ensure their own and others’ safety.  And this is occurring not just in rural communities miles from the nearest “modern” clinic–this is happening in your mother’s, your sister’s, or your daughter’s hospital room in the center of La Paz city.

27 de Agosto: No se necesita receta

Posted in Bolivia, health care, sexuality, United States with tags , , , , , , , , on August 27, 2010 by eugeniadealtura

This week at Womanist Musings, I’ve written a post on the difference in over-the-counter access to drugs and other items in the U.S. versus Latin America, particularly Bolivia. What inspired the posting?  A visit to a U.S. pharmacy where customers can now purchase vibrating sex toys right off the shelf, without visiting a sex toy store or buying online.  Check out the posting here.

1 de Mayo: Siempre equivocada

Posted in Bolivia, health care with tags , , , , on May 1, 2010 by eugeniadealtura

This week, the La Paz daily La Razón reported on a slew of complaints being leveled by patients of the local Hospital de Clínicas  and their families for mistreatment and misinformation. Apparently, the Minister of Transparency and Against Corruption, Nardi Suxo, visited the large public hospital in order to speak with patients in person about their complaints, which are largely that, “‘[they] do not have information about their family members or about the treatment that they must follow, in addition to mistreatment'” (all translations are my own).

Regarding the visit, the director of the hospital, Dr. Eduardo Chávez Lazo, remarked that, “‘it has been seen that the care (at the hospital) is very appropriate, and in any case, the Minister has come to verify this in person.'”  With respect to patients’ complaints, Chávez said, “‘a patient, when s/he is sick, changes her/his character and way of being, and becomes depressed, whiny, and aggressive… When one is sick, the treatment that the patient receives is not what s/he expects, and this results in complaints.”

To avoid the long lines and mistreatment at many public hospitals, many people go to small private clinics like these ones in busy market districts of La Paz.  The care here is not necessarily any better than at the larger facilities.

In my mind, this piece is a non-story.  I have become so accustomed to hearing women state that they are “afraid” to go to medical centers, that sometimes I forget to ask why.  When I do remember, they say that they are afraid of being yelled at and chided for: crying out during childbirth; for not going to prenatal visits; for coming in to the hospital either too soon, or too late, in labor, or for having any request at all during their hospital stay.  Indigenous women are often yelled at for not understanding Spanish, for requesting food and hot beverages during labor, for wanting to give birth in the traditional squatting position, for asking to be bundled in blankets during labor, and for requesting to take the placenta home after the birth. (Consuming hot food and drink and being wrapped in blankets are indigenous birth rituals that heat the body and facilitate cervical and pelvic dilation for birth, while burying the placenta protects the child from illness throughout its life.)

Dr. Chávez’s dismissal of patient complaints is, although infuriating, completely unsurprising. The fact is that, with regards to medical care, the old customer service adage is reversed: if the customer is always right, in Bolivia, the patient is always wrong. In Bolivia, where higher education is less of a universal right than a luxury for the few, poorer, uneducated Bolivians are taught to treat doctors and other professionals as their superiors.  Most Bolivians recognize that they are being mistreated at medical facilities, but rather than confronting well educated doctors and nurses about the abuse, they prefer to simply not go to the doctor.  In addition, many indigenous Bolivians prefer to visit medical providers from their own communities, rather than western medical institutions.  The government, rather than dealing with the mistreatment, instead institutes poorly conceived, incentive-based health care programs like the Bono Juana Azurduy or the tuberculosis testing program to lure patients into hospitals.  They do this rather than deal with the abuse because they are more concerned with Bolivia’s international reputation, which is scarred by high maternal mortality and other health statistics, than with the health of actual Bolivians.

This La Razón article may tell us nothing new, but at least it gets the word out there about the poor state of affairs at many Bolivian medical facilities.  While medical infrastructure and technology in the country have improved considerably over the past several decades, these achievements will not bring patients in the door.  And they will not substitute for comprehensive, sensitive, culturally competent, and non-judgmental care.

17 de Abril: ¿Por qué no, “algo porque sí”?

Posted in Bolivia, health care with tags , , , , , , , on April 17, 2010 by eugeniadealtura

This week, the La Paz daily La Prensa reported on four initiatives being undertaken in city of El Alto to combat tuberculosis (TB).  Luisa Mendizábal, the coordinator of the program, notes that El Alto saw 700 confirmed cases of TB in 2009.  One of the initiatives being used to combat the disease, however, has little to do with TB itself–instead, it uses pregnant women as, essentially, bounty hunters for potentially infected individuals.  The program is tellingly titled “Algo por Algo,” or “something for something”–as in, do something for us, and we’ll do something for you.

It works like this: if a pregnant woman brings an individual with symptoms of TB to her prenatal checkup, then she will not have to wait in line with the dozens of other expectant mothers to be seen.  Instead, she’ll pass directly through the double doors to see the doctor.  It bears mentioning that these women are forced to wait in line for hours because of their participation in another government program: the Bono Juana Azurduy.  As I have previously reported, the Bono Juana Azurduy pays pregnant women to go to state-run medical facilities for prenatal care and for the birth, rather than having their children at home.  While poverty has led expectant mothers to queue for hours to receive a bit of cash and what is often described as a cursory checkup, now Algo por Algo offers women the opportunity to cut down on their wait time by dragging a phlegmy, coughing, potentially TB-infected individual along with them.  Although TB is known to be contagious and potentially fatal, proponents of Algo por Algo are putting pregnant women at risk by giving them incentives to be in close proximity with infected individuals.

In part, I understand the impulse for programs like the Bono Juana Azurduy and Algo por Algo. Many women report being scared of health facilities, either because of their unfamiliarity, or because of the mistreatment that many have experienced there.  In the face of this fear, women often choose to have their children at home, where they are more likely to be attended in the birth by family members or by no one than by a midwife, whose services cost money.  The government officials who created the Bono probably genuinely hoped to reduce maternal deaths by getting women to the hospital.  (They also likely hoped to reduce the practice of traditional medicine and birthing methods.)  But programs like these are inherently flawed, for a number of reasons: they do not address the mistreatment that consistently drives women away from medical facilities, and they may expose pregnant women to TB, for example.

There’s another problem with incentive-based health programs, however, that I find much more fundamental: quality health care should NOT be something you get in exchange for something else.  Health care should be, and in some countries is, a basic human right.  A universal right. When reductions in maternal mortality or TB rates are achieved through cajoling and manipulation, rather than empowerment and education, I am uneasy to call this a true “win.” Rather than “something for something,” health care should be a question of “something just because.

6 de Marzo: Y…la Juana Azurduy estaría de acuerdo?

Posted in Bolivia, health care with tags , , , , , on March 6, 2010 by eugeniadealtura

A few days ago, the Inter Press Service News Agency published an article on Bolivia’s controversial “Bono Juana Azurduy,” a state subsidy that pays pregnant women to go to public health centers, instead of having their children at home.  The Bono grants women a total of about $250US that is distributed in 17 separate payments when women present for prenatal visits, for the birth of the child, and for routine check-ups in the first two years of the child’s life.  Although you would not know it by reading this article, the subsidy–named after a famous female revolutionary leader who commanded patriot forces against the Spanish in Bolivia’s battle for independence–has drawn considerable criticism from some sectors of the women’s rights and healthcare communities in Bolivia.

According to the Ministry of Health, the purpose of the Bono, which was introduced in 2009, is to reduce maternal mortality rates by encouraging women to have their children in health centers rather than in the home.  Bolivia’s maternal mortality rate is the second-highest in Latin America ( after Haiti), taking the lives of 222 women per 100,000 live births.  The leading causes of maternal death in Bolivia are believed to be hemorrhage, eclampsia, and complications from abortion.  The Bono Juana Azurduy is effective in 98% of the country’s municipalities, and operates in conjunction with a universal maternal-child insurance program (called the SUMI), so that all costs of pregnancy and childbirth are shouldered by the state.

So, what’s the problem with the Bono?  Apart from any philosophical criticisms one may have for paying women to go to the doctor, it is clear in that the program has put additional stress on a state health system that was already struggling.  By creating incentives for women to go to health posts without increasing staff or other resources at these centers, the program is leading to overworked doctors and nurses and to a poorer quality of care.  The IPS article notes that the numbers of pregnant women visiting health centers has increased by a factor of six since the introduction of the Bono.  Some women report waiting several hours to be seen after traveling large distances to get to the centers.  As former Minister of Health Ramiro Tapia said, “‘At the moment there is a gap between the good intentions and the day-to-day running of the programme.'”

Apart from its poor functioning, some members of feminist and community health groups take issue with the intentions of the Bono Juana Azurduy, arguing that it represents an attempt by the state to control women’s reproduction, by influencing how and when they have children.  Activists working to protect the rights of indigenous women to practice traditional pregnancy rituals and birth techniques argue that the Bono is designed to discourage women from giving birth at home with the assistance of midwives.  Many women prefer to give birth at home, where a midwife will help them to keep their bodies warm with blankets, hot chocolate, and soup, and where they are permitted to give birth in the traditional squatting position.  Women often report being scared of western medical providers and facilities, where they say they are prevented from crying out in pain, forced to give birth on their backs in cold hospital rooms, and left for hours following labor without being served anything to eat.  Although the financial incentive of the Bono has led more women to go to health posts, activists argue that little has been done to reduce discrimination against indigenous patients or to take their birth and pregnancy preferences into account.

Organizations fighting for the decriminalization of abortion contend that the Bono also represents an attempt by the state to reduce illegal abortion rates by providing incentives for women to continue their pregnancies.  If true, activists believe that this impulse has more to do with improving Bolivia’s reputation internationally than with improving local women’s lives.  As I have mentioned previously in the blog, unwanted pregnancy and abortion rates are higher in Bolivia than in any other country in the region, aside from Haiti, which government officials may feel “reflects poorly” on the country.  However, providing women with a subsidy of $258US over a period of three years does little to offset the long-term costs of raising a child until adulthood, and will most likely have no impact on abortion rates–or on maternal deaths due to abortion.

Since the Bono’s namesake, Juana Azurduy, lived about 200 years ago and historical sources on her are somewhat scarce, it is difficult to imagine how she would feel about the recent maternal-child subsidy.  We know that Azurduy spent some time in a convent as an adolescent, but her rebellious behavior had her kicked out.  We know that she had a daughter and several sons, and evidently participated in combat against the Spanish during the course of her pregnancies.  Did Azurduy ever rely on a midwife to deliver her child?  Did she ever have an abortion?  Did she feel she controlled her own reproduction–and was this even important to her?  How would she feel, I wonder, to know that her name–and feminist and revolutionary legacy–are being used to characterize this Bono, which some see as a government incursion into women’s reproductive autonomy?

As I mentioned in an earlier posting, Monday, March 8 is International Women’s Day.  To commemorate the date, feminist blog Gender Across Borders is hosting “Blog for International Women’s Day,” for which Eugenia de Altura and dozens of other blogs will be reflecting on the theme of “Equal Rights, Equal Opportunity: Progress for All.”  So, come back and visit the site this Monday, and check out all the other blogs that are participating in the event.