Upon arrival into the La Paz, Bolivia airport the notion was instantly reinforced that I had entered a third world country. Despite my native Bolivian preceptor Dr. Oscar Lanza’s efforts to convince me that there is no such thing as a third world country, by prompting the question, “where are the other two worlds, we are all part of one world together.” It was apparent that this country was far different from my country of origin in the United States. The airport was small and after a lengthy discussion with the customs officers (entirely in Spanish), I finally convinced them with my entrance letters and home residence in La Paz, that I should be allowed to enter the country legally, but unfortunately I was not cleared until 1:00 am. As I drove through the quiet streets of La Paz, I could not help but notice that hollow red brick homes towered on cement stilts hanging off the sides of steep hills and cliffs. They were built, seemingly, on top of one another and if any tectonic shifting were to occur hundreds of families would plummet to their deaths. Despite the obvious poverty evident throughout every make-shift home, barred store window and scattered sidewalk mounds housing chilly persons in dirt stained blankets, I could not help but be impressed by the effort made to create beautiful shrubbery designs and soot covered pink flowers which ran down the middle of the downtown streets. This little insight provided affirmation that even the populace of these so-called “poor-third-world-countries” want to beautify and take pride in their homeland and helped me realize that we really are not that different after all.
Statement of the Problem
The Bolivians have an aphorism that states “when God designed Bolivia he gave the country every single natural resource needed for self-sustenance and provide richly for its citizens.” The country lays claim to many natural resources including large petroleum deposits and massive gold and silver mining operations. The country boasts miles of prosperous agricultural lands providing work for many of the poorest residents. The landscape varies from desert salt flats in the south, to the humid Amazon jungle in the north and the impressive Andes’ Mountains which span the entire country presenting its majestic peaks and substantial glaciers which provide pure sources of water. Despite the countries obvious assets, it continues to struggle financially and, more related to my topic, it suffers from substandard nutrition and health. Many of the country’s poorest citizens lack access to nutritious food and basic healthcare. At first glace, I can assume many explanations for such sorry access to basic needs - my assumptions include the obvious such as poverty, rural living, or lack of or inconsistent education and, if access is afforded, then poor hygiene, decreased access to sanitation services and potable water for cooking, showering and hand washing. I have described these Bolivian predicaments in minimal detail merely skimming their complexity, and their deeply seeded social and political implications. Once contemplating their immensity you might find yourself at odds with the country as I did, feeling as though anything I can do, would not address the problem in its entirety or even place a dent in the massive poverty/health/nutrition crisis that this country faces.
Context/Organization Setting and Project
A few days after my arrival I was introduced to the Centro Comunal Del Carmen, a medical clinic focused on serving women and children. The clinic is comprised of three separate clinics, the other two being Pasankeri and Llojeta. These clinics are funded primarily by two agencies, the Madrid Paz y Solidaridad located in Spain and secondly, a German organization named CBM. There is also minimal support from the Cuban government, in the form of Cuban doctors working in the Pasankeri clinic. The clinic’s mission focuses primarily on what they call “primary care.” Primary care in Bolivia is not the same as in the United States, in the Bolivian context it refers to preventative medicine, or in other words, public health education. Because Bolivia does not have the infrastructure to manage large numbers of sick persons, the doctors (trained in western medicine techniques) must turn towards prevention as their greatest defense against severe sickness and death in the case of children. The three clinics focus a great deal on preventative measures and education and have created a program called “Crecimiento y Desarrollo” (Growth and Development program – C&D) which encompasses part of their mission, and to enroll as many children and mothers as possible. Promotion of this program ensures that children are seen on a monthly basis and therefore watched closely for signs of malnutrition, acute diarrheal episodes and complications including dehydration and other significant illness such as acute respiratory infection. This monthly visit is also used to educate parents regarding a variety of topics ranging from the care and feeding of newborns, hygiene practices, the importance of washing hands and using bathrooms and discussions on healthy diets rich in fruits and vegetables. These clinics are built along the outskirts of the city of La Paz, bordering the neighboring city of El Alto. El Alto is notoriously known for its soaring rates of extreme poverty, lack of clean water and minimal sewage services. When navigating El Alto, you know the city limits because seen along telephone poles are stuffed scare-crows hanging by their necks, warning people of the fate that awaits them due to violence and crime. Theft is rampant in El Alto, the enticement to steal is for provisions that will prolong life another day; starvation makes burglary profoundly tempting. It is the goal and mission of these clinics to provide quality medical care for the poorest of the neighborhoods. The clinics Llojeta and Pasankeri are proudly free-of-charge and Centro Comunal Del Carmen charges a minimal fee of five Bolivianos, an equivalency just shy of one US dollar. However, it is difficult to enroll children in the C&D program because parents work long days on the streets, doing whatever is necessary to earn a living and/or because the later two clinics are relatively new and more marketing is needed.
The clinic is desirous to obtain more funding to demonstrate statistical proof that their methods and model have had an impact on the community; therefore they have been very pro-active in accumulating statistical data from their patients. Data was collected for children 0-5 years old in the following categories: Acute Respiratory infections (with or without pneumonia), Acute Diarrheal infections (with or without dehydration), Skin eruptions, hospital admission, and favorable outcomes. The same information was collected for 6-14 year olds, but with additional conditions such as acute gastrointestinal, pulmonary, genitourinary and dermatological infections. Other data sets were collected regarding malnutrition status, mental health and immunization status. These large data sets were nothing short of extraordinary and a large effort was required on the part of the clinic staff to compile these numbers. All the data was then compiled into a 55 page annual report, detailing various sorts of percentages and numerical informational data. When reviewing this report one mistake however, was noted by Dr. Oscar Lanza. All of the data was subdivided as ages 0-3 years and 3-5 years. This division of ages is not in accordance with the National Institute of Health (NIH) and therefore all their calculated tables are incomparable with the national database. This is because the NIH requires that childhood data be categorized starting with ages 0-1 years and subsequently ages 2-5 years. It is important for the Centro Comunal Del Carmen to submit their data to this database, as well as compare Bolivian health rates with those of other countries. This age discrepancy led to me and Erin Littman’s project; we were assigned to re-stratify the data into the correct age groups as defined by the NIH.
All of the data has been acquired for years by grouping children ages of 0-3 and 3-5. Not only has the incorrect age groupings not allowed comparisons and submissions to the NIH, also it has not allowed any assessment regarding the critical age of change; one year old. In Bolivia, this age is when many adjustments occur, the child is often un-swaddled for long periods of time, experimenting with new foods, learning to walk and the mother might be pre-occupied with a forthcoming new baby. Once the data is re-tabulated in order to fulfill NIH requirements, we produced two main objectives. The primary objective being to identify the most vulnerable age group (i.e. ages 0-<1 or 1-5). Our secondary objective was to identify the most vulnerable age group, further categorized by one of the clinics three programs (Crecimiento & Desarollo – C&D, Jardin Infantil – JI or Poblacion). The importance of our secondary objective was to obtain evidence of the clinics failure or success regarding increased rates of health. If success was found, we hypothesized that the highest health rates would be linked with the C&D program. This program, as described previously, is based on preventative medicine (or primary care) and the child is seen monthly for General checkups monitoring growth and development status.
Results Achieved
Our original goal was to re-calculate the acute-illness tables, malnutrition rates and attempt re-tabulation of ages 6-14. Because of the vast amount of data and our primary limitation; the language barrier, we simply focused on acute illness for children 0-5 years. Because none of the staff spoke English, understanding, computing and writing a report in Spanish was an enjoyable yet daunting challenge. After many days of difficult data interpretation, a few mistakes and formatting issues, we were able to complete four tables (Pages 12-13).
The tables signify the following:
1. Table 1: Medical intervention for children ages 0-5 years enrolled in Jardine Infantil (JI)
2. Table 2: Medical intervention for children ages 0-5 years enrolled in the Poblacion en General.
3. Table 3: Medical intervention for children ages 0-5 years enrolled in Crecimiento & Desarollo program (C&D)
4. Table 4: Medical intervention for children ages 0-5 years enrolled in C&D, JI & Poblacion.
Once the tables were computed two comparisons were made. First, a comparison of the individual tables 1-3 comprising 0-<1 years and 1-5 years of all three groups: JI, C&D and Población. This comparison enabled us to make the following statement and ultimately answer our primary objective.[1]
§ The healthiest group is: 0-<1 of the C&D group (TABLE 3, 79.4%)
§ The least healthy group is: 1-5 of the Poblacion en General (TABLE 2, 21.2%)
§ The group with the highest amount of respiratory infection: 1-5 of the Poblacion en General (TABLE 2, 53.6%)
§ The group with the least amount of respiratory infection: 0-<1 of the C&D group (TABLE 3, 17.6%)
§ The group with the highest amount of EDA: 1-5 years of the C&D group (TABLE 3, 9.7%)
§ The group with the least amount of EDA: 1-5 years of the JI group (TABLE 1, 1.5%)
§ The group with the highest rate of other pathologies: 0-<1 years of the Poblacion en General (TABLE 2, 20.6%)
§ The group with the least amount of other pathologies: 1-5 years of the JI group (TABLE 1, 6.0%)
§ The group with the highest amount of reconsults: males 0-<1 years of the Poblacion group (TABLE 2, 90.9%)
§ The group with the least amount of reconsults: males 0-<1 years of the C&D group (TABLE 3, 19.2%)
Our conclusion, based on the aforementioned bullet points, we have identified the most vulnerable group, as was our initial purpose. The group identified was the children ages 1-5 years of the Poblacion en General. This group displayed the lowest healthy percentages and the highest rates of respiratory infection of all groups studied.
Our second comparison was of TABLE 4; strictly contrasting the age groups 0-<1 years with 1-5 years, all three groups combined (C&D, JI and Poblacion).
§ The healthiest group is: 0-<1 ages with a 58.9% (compared to 44.9% of the 1-5)
§ The least healthy group is: 1-5 ages
§ The highest amount of respiratory infection: 1-5 ages (with 38.9%)
§ The Least amount of respiratory infection: 0-<1 year olds (with 24.7%)
§ The highest amount of EDA: 1-5 ages (with 5.4%)
§ The least amount of EDA: 0-<1 ages (with 4.1%)
§ The highest amount of other pathologies: 0-<1 ages (with 11.0%)
§ The least amount of other pathologies: 1-5 ages (with 9.5%)
§ The highest amount of reconsults: 1-5 ages (with males 62.0% & females 56.4%)
§ The least amount of reconsults: 0-<1 ages (with males 40.5% & females 47.2%)
Our conclusion, based on the aforementioned bullet points (regarding TABLE 4), we identified the most vulnerable age group as the ages of 1-5 years (outlined in red TABLE 4). This group displayed the lowest healthy percentages, and the highest rates of acute respiratory and diarrheal infections. The age group 1-5 also had the highest rates of reconsults possibly indicating advanced severity of illness compared to the 0-<1 age group.
The significance of our results was three fold. First, by identifying the least healthy group, Poblacion ages 1-5 years (health rate of merely 21%), the clinic can now change their medical and public health approach to this specific age group. Because it is so apparent that these children suffer greatly from acute infections, when a child does arrive at the clinic, health workers can tailor their care and preventative health education to the specific needs of this population. Via group discussion many theories were proposed by the staff explaining the low health rates (21% TABLE 2), but no one anticipated such a low rate of health. Some of these theories of course included cessation of breast feeding which usually occurs around this age therefore, those children become susceptible to Bolivia’s elevated malnutrition rates. Also many governmental programs have been designed to decrease the infant mortality rate but, their scope usually supports children until the age of one.
Second, by identifying the age group most vulnerable as ages 1-5 years, the clinic had insights regarding their current efforts. For example the staff noted when community education is provided in the indigenous language of Aymara, even though the direct translation of the word “child” means “child,” culturally the Aymara people tend to relate the word “child” with the word “infant.” This simple oversight, is confirmed since preventative education functions effectively for infants (0-<1years) evident by the excellent health rate of 79.4% (TABLE 3) but not as much for children 1-5 years evident by the average health rate of 54.3% (TABLE 3). Therefore, these data have indicated that more specificity is needed regarding education, instead of saying “children etc….” the age range must be clearly stated, this will avoid any confusion or meaning lost in translation.
Finally, by identifying the highest health rate of 79.4% (Table 3) for 0-<1 years in the C&D program (compared to averages of 50%), this granted evidence supporting the successful medical methods utilized by Centro Comunal del Carmen. The C&D program is the best health program that the clinic has to offer, and these data provide strong support on behalf of grant proposals and reassurance that the C&D program is outstanding at reducing rates of acute infection. It was proposed during the presentation, that Centro Comunal del Carmnen could become a medical model for other third world countries due to their tremendous success.
[1] The tables and conclusions are color coded, Blue Generally means “better” and yellow generally means “worse.” When viewing the graphs you can see this colorful trend and can loosely identify which group is most vulnerable). The colors also aided in presentation/understanding purposes for the clinic.
