Masks, Public Health Tents, and Sweeping Closures

That is what swine flu in Bolivia looks like (here called Influenza A). About 100 cases have been reported here, mainly in Santa Cruz. There is a full-blown panic here that to a certain extent overlaps what occurred in the U.S. yet with local particularities and concerns. Overall, it appears that the impact here is and will be greater than in the U.S.

When we arrived two weeks ago, we were met by a team of 4 or 5 young officials (medical students? nurses? young doctors? It was hard to tell, they were all in their mid-20s and there were a few guys and a few women). They each wore two face masks and a white lab coat. They met each passenger with a clipboard and asked us while we stood in line waiting to clear immigration a series of questions – name, city of origin, if we had any flu symptoms, address in Bolivia, etc.

Later that week while talking to one of Miguel’s cousins, we found out his classes (he’s a lecturer at Rene Moreno’s campus in Montero) had been cancelled for 2 weeks due to swine flu, since there were a few confirmed cases in the vicinity.

Then upon our arrival to La Paz, I found out that *all* schools are closed (public, private, etc) for two weeks due to swine flu. This “vacation” overlaps with some schools’ winter vacation, but in many cases simply extends it for an extra week or two (particularly in the private schools that have mandated closures), and it is discussed as a closure for public health reasons, not as a scheduled break.

This includes all offices and facilities at UMSA: administration offices, laboratories, libraries, etc. Usually during a break classes are not held, but other activities continue. I had hoped to visit the laboratories and make several appointments with university officials and due to the closure this may not be possible (this is frustrating but at least I can still get together and catch up with friends in other venues).

According to a friend of mine, unlike previous “vacations” where classes are cancelled but facilities are open, they are being very strict, even denying users of the campus in Cota-Cota access unless they have a special permission de urgencia (obtained through a tramite, of course), which she and other laboratory personnel spent this week trying to obtain so that they don’t leave their experiments, samples, etc unattended for two weeks. She also told me that they have armed police at the gates to the U for control purposes.

It is common to see people walking around wearing a mask. Newspapers are getting some flack from doctors for telling people to go to the hospital for an “immediate” swine flu/influenza A test if they are exhibiting *any* cold-like symptoms (there’s not the capacity in terms of personnel, reagents, or need to do this, though apparently people have been showing up in huge numbers). Today La Razón reports that a cold front is expected, which will increase the risk and prevalence of this flu. Evo is sending 900 doctors to the campo to deal with the flu. Yesterday there was a tent staffed by medical students in the Plaza Avaroa to educate passers-by about the flu. And it goes on and on.

I am confused: I thought that this flu turns out to be a relatively mild strain (there have been no deaths in Bolivia). So why such a strong (and heavy handed) response? I’ve heard various answers. The one I am most convinced by is that many people in Bolivia, particularly La Paz, have serious underlying respiratory issues including TB, asthma, allergies, etc. The combination could be difficult to treat, especially at altitude. That may very well be the case, but I can’t help wonder what could be accomplished if all this effort went towards some other project or campaign at this point.

A Constant in Bolivian Bioscience…

Is the lack of reagents (“reactivos” in Spanish) for conducting experiments. Delicate, temperature sensitive reagents get caught up in customs and expire or they never arrive, or the tramites don’t go through to purchase necessary supplies. Often it is difficult to obtain the same brand and type of reagents, so researchers have to constantly re-standardize their experiments.

While this all may be a challenge for academic researchers, for people working to diagnose certain maladies using molecular or serological techniques (which require much of the same reagents and equipment as academic labs and in Bolivia are often conducted in hybrid diagnostic/research laboratory facilities) this can be a public health issue.

The on-going dengue outbreak in Santa Cruz and elsewhere in the lowlands is a case in point. El Deber reports that there may be 50,000 cases of dengue reported in Bolivia by the end of March. The main diagnostic facility in Santa Cruz, CENETROP, has asked for more funds for reagents for diagnostics or else it will not be able to continue offering tests for dengue and comparisons of the strains in Bolivia, because it has run out of reagents , having done more than 7200 tests when it only had supplies for 6000.

CENETROP (and other Bolivian research institutes) often develop their own less expensive tests to offer to the Bolivian public specifically to provide rapid, accurate information about diseases of great significance to public health. I’d wager they are using locally-standardized diagnostic procedures here, as opposed to expensive commercial kits (which many Bolivians argue are not as accurate because they do not take into account the specific biochemistry of local strains of pathogens, but that’s another post about the ideology of localism in biomedicine and bioscience). What’s tragic is that due to tramites, transport difficulties, and perhaps regional myopia a fundamental tool in controlling the dengue outbreak could be lost.

Urine Therapy and Home Remedies

I want to follow up on Kate’s brief post on this story about the woman who died in rural Santa Cruz after allegedly being injected with urine.  I agree with Kate that part of the press attention to this case is due to the fact that the women involved appear to be urban and middle-class, and the woman who allegedly gave the urine injection is something of a celebrity.  But here, I want to talk briefly about the role of urine in curing practices in highland Bolivia.

While the idea of urine therapy sounds strange to some in the U.S., it doesn’t to many Bolivians.  In rural highland Bolivia, it can be wiped with a cloth over the skin of children suffering from fever or other minor ailments.  Baby chickens are given human urine to drink while they are small to prevent them from dying.  Some reported that boys would urinate and put the urine on cuts and scrapes during soccer games, as a temporary cure.

Urine therapy appears to be fairly common throughout the world and history.  A quick google search for “urine therapy” will bring up numerous groups in the U.S. and elsewhere with advice on the practice.  Even the American Cancer Society doesn’t dismiss the idea that drinking urine or putting it on the skin might be helpful, although they admit no studies have shown this.  Such practices may not help, but they don’t appear to be harmful either.

What seems to be unique about this case are that first, the patient died (instead of just not recovering) and second, that she was effectively injected with urine rather than drinking it or rubbing it on the skin.  I wonder if this is in part because in Bolivia, injections are generally seen to be more powerful healing agents than pills or other oral medicines.  People often specifically request injections because they assume they will be more efficacious and fast-acting.

I also wonder about the question of when and where urine therapy is appropriate.  While it seemed to me to be a fairly common home remedy, I never heard of it being used in a hospital setting, or as a complement to western medicine.  It’s not just that doctors are generally not excited about their patients being injected with things they didn’t sign off on, but also the idea that certain treatments are appropriate to particular contexts.  One also sees this in the religious sphere, where the practices that are appropriate in a Catholic Church are not the same as those proper for making offerings to Pachamama — and vice versa.  Doctors are useful but, for example, one should not consult them to treat karisiri attacks.  Likewise, I wonder if urine therapy is simply “out of place” in a hospital.  It would be interesting to know how Bolivians are responding to this story.

The woman accused of giving the injection has denied the charges, and I am in no position to judge her guilt.  What is interesting to me with this case is the fact that a relatively common practice in Bolivia (at least in my experience) is being reworked as a bizarre practice, rather than this being presented as an extreme variant of a common home remedy.

More coverage, more of the same?

Is it just my impression, or has there been an increase in English-language coverage on Bolivia over the past 6 months? Not only was there the long piece in the New York Times’ Travel Supplement in the Fall (post is below), but there was a recent front-page article on Bolivia’s lithium resources and the “problems” nationalism causes for multinational corporations hoping to use lithium in their products. There was also significant coverage of the tit-for-tat expulsions of the Bolivian and U.S. ambassadors, and the recent constitutional referendum was covered by prominent newspapers.

Then today I saw that Clare posted this link about a woman who died from an injection of urine. I am particularly surprised that this received as much attention as it did. I wonder if it is because two “prominent” individuals (read: middle/upper class and likely identifying as white) were involved. That is, perhaps these women don’t fit the stereotype of which Bolivians are *supposed* to use medical practices that seem, to many of us, dangerous or “gross.”

Cuban kharisiris?

Ok, sort of a cheap-shot provocative title to get ya’ll to read this. But that doesn’t change the content of the long article published in Wednesday’s La Razón.

A young woman from Oruro, Beatriz, who three years ago obtained a scholarship to a Cuban medical school, died while abroad. Her parents were told that the cause of death was a cerebral hemorrhage. When her body was returned to the family in Bolivia, they had an autopsy performed and found most of her internal organs had been removed, including her brain. Her sister claimed that Cuban authorities wanted to perform an autopsy in El Alto, using Cuban doctors, but instead the family was able to conduct the autopsy in the Hospital de Clinicas.

The article quotes family members as saying that they told authorities they did not want anything to be taken from the body (using the term sacar). It also asserts that the Cuban authorities are threatening to break off diplomatic ties with the home municipality of the family if the family members continue investigating.

The article ends by delineating a case from 2002, almost identical to this one.

Let’s look structurally at what happened: a young woman died while far away from her family, in a country that provides significant health care aid to Bolivia. Beatriz was young, so her death was unexpected. No one close to her knows the details of what happened. When her body arrived, her family was suspicious enough to demand an autopsy conducted by non-Cuban doctors. They found that most of her organs had been removed. The family then claims that they were threatened and told to keep it quiet by Cuban authorities.

Regardless of if Beatriz’ organs “really” were stolen – though I am inclined to think something fishy happened – I cannot help but be reminded of the figure of the kharisiri.  Kharisiris have often been represented as outsiders, as whites, even sometimes as doctors.  Usually they are visitors to a community in the Andes, where they then suck out the fat and life source of their victims.  Here, we have bodies being returned to Bolivia from Cuba with their vital organs – the ones fundamental to life itself – missing.

Who better to suck fat and take vital substances than doctors, with their intimate knowledge of the human body? And where better to do so than away from the watchful eyes of kin, when the victim is herself also training to be doctor and not suspicious of health care settings?

I wonder if this narrative is an updated (post-millennial?) version of the kharisiri story, one modified and suited for mobile, increasingly urban and transnational populations.  At least that’s one relatively simplistic reading. The figure of the fat-suckers are marked by nationality and occupation – Cuban doctors. (Remember the hesitance by Beatriz’ family to have Cuban doctors working in El Alto perform the autopsy.) That Cubans are now the subject of fear, anxiety, and suspicion is new to me if not, upon reflection, surprising, as rumors that Cubans are taking over the medical establishment and/or are working as spies have caused controversy before (meaning that alignments and alliances between countries in the Latin American left are more complex and problematic than is often assumed by casual observers).

After all, Beatriz was from Curahuara de Carangas, Oruro, not a major urban center, yet she was able attend a Cuban medical school (belying stereotypical if outdated assumptions of rural populations being static or fixed in place).  This is consistent with analyses – most notably by Mary Weismantel – that discuss the kharisiri as a potent distillation of the fears, anxieties, and understandings of the operative power relationships under capitalism.    Here the Cubans, then, are the ones holding the purse strings, power, and promise of a better future if you follow their rules and do so on their turf.  No longer does the kharisiri find you in your natal community, entering as an outsider, but rather you are always a target by virtue of leaving your community.  The need to do so, of course, is often driven by economic forces beyond one’s control.

Deaths, Doctors, and Beliefs

The Informe Semanal in the June 24th, 2007 edition of La Razón was filled with depressing statistics about the maternal mortality rate in Bolivia. The Pan-American Health Organization had just released a report on the state of maternal health in the Americas, and Bolivia ranked near the bottom (235 women die for every 100,000 live births), edging out Haiti for the worst maternal mortality statistics in the hemisphere.

However, the report seems to place blame for these statistics on women themselves, and elides or downplays the role that the formal governmental health system has in contributing to Bolivia’s distressingly high rate of maternal death. One section of the report proclaims that “Creencias ponen al país en la cima de mortalidad materna. Un choque cultural. La atención médica que se presta en el país es distinta a la creencia que tiene la mujer en el momento del parto.”

But what are these “creencias”? The article mentions that women, especially women of indigenous background, believe that a woman’s body is like the earth, it prepares for growing life, and then it does – ok, but how does this lead to such mortality statistics, exactly? And sure, women might prefer to give birth in a warm environment, maybe squatting or sitting up at a nearly 90 degree angle, and that’s not available in hospitals, where women are expected to assume a “posición ginecológica.” Once again, how are these beliefs themselves necessarily detrimental to a woman’s health during childbirth, and why, in my reading, does the article seem to be implying that the beliefs of women need to change, not the practices of physicians in hospitals and health posts? In other words, how are these ideas different from many beliefs that the medical community have regarding what is an appropriate way for a woman to give birth?

The article continues to say that many “mujeres con raíces aymaras y quechuas” believe that birth is something “normal.” Well, isn’t it? Sure, can be risky, and there are medical issues and complications that arise, but isn’t childbirth a normal part of life? Here it seems to be painted as an abnormality, a disease, exactly the kind of conception that feminists have been working against for decades.

Perhaps even more worrisome, to me at least, is that the articles focus on only a few statistics, most notably that “53% de muertes maternas se dan por partos en domicilios.” There is no discussion whatsoever of the remaining 47% of deaths that occur in clinical settings. Let’s face it: 53% is not really that different from 47%. Furthermore, the Informe notes that 82% of “non-indigenous women” give birth in a hospital, while only 51% of indigenous women do. But how these two groups are defined is not mentioned. Still, considering these statistics and assuming that they are correct, that means that deaths within clinical settings are still inexcusably high, a fact that is not discussed in any great detail, instead the Informe focuses on rural women or women who give birth in their homes and their “creencias.”

Why not focus on the incredible systemic problems with the health care system in Bolivia? There are frequently unsanitary conditions in hospitals, lack of equipment, and lack of medicine. Furthermore, though doctors are frequently well-trained, there’s not much one can do in an old, run-down building with non-functioning equipment (and, no doubt, leads to many women avoiding hospitals where they will receive poor care and often be treated poorly themselves). Finally, the concept of childbirth as a disease, as I discussed above, is somewhat off-putting for many women, and with good reason, especially since it seems that elsewhere in the world the pendulum is swinging in the opposite direction. For instance, in the U.S. and Europe, more and more hospitals and obstetricians (though by no means all) are recognizing that having a woman in a “delivery room,” flat on her back, is not the best way to give birth for many psychological and physical reasons. These days, the norm seems to be that hospitals present their birthing suites as homey and welcoming, where women have some say in their childbirth process. In such birthing rooms, women often can labor, deliver, and recover all in one room, with their babies kept in with them. Often, women have the opportunity to use a whirlpool tub, walk around, use a birthing bar or a birthing bed (meaning she’s not flat on her back), or otherwise try to make themselves as comfortable as possible. Coaches, partners, doulas, and other support people are generally allowed into the room, if the woman requests. In other words, the trend in the U.S. and Europe seems to be (based on my own limited experience) back towards making the birth experience as personal as possible and less clinical. This new model sounds like the attitudes of many women in Bolivia surrounding childbirth, and it is worrisome to see such ideas painted as mere “beliefs,” while the accepted clinical model of childbirth is left unquestioned, despite evidence that the clinical model in Bolivia isn’t faring too well, either.

Overall, the articles reinforce the notion of rural or indigenous women as backward and driven by belief or culture, while doctors and hospitals are implied to be the paragons of modern, Western scientific rationality (assumptions that are not nearly as clear-cut in practice). This is despite the statistics presented in the Informe itself that contradicts, or at least troubles, these assumptions. It is this blindness that is deeply concerning to me, for it strips women of their ability to express their attitudes and desires towards their childbirth experience. Such opinions, clearly, are not being heard nor respected.

Ideas of Convenience, Environmentalism, and Diapers

As I was reading Clare’s last post, I couldn’t help but be reminded of a recent series of conversations I had while in Bolivia. About diapers.

Let me explain. Miguel & I are expecting, due around Christmas. Since this is our first kid there are lots of decisions to be made: breast or bottle, co-sleeping or separate room, natural childbirth or the best drugs money can buy, and of course, disposable or cotton diapers. The last pairing took me by surprise, as I’d always expected to use disposable diapers. The extent of my reflection on this issue ran to thinking of maybe the unbleached or more natural kind, but still firmly within the disposable category. To me, it was a foregone conclusion, since no one uses cotton diapers any more, right? They’re more prone to leak, more work, and generally outdated, there’s no good argument for them!

Not exactly. While we were visiting family in Bolivia in June, my pregnancy was a frequent topic of family discussion (babies are in the air in Miguel’s family — Miguel’s cousin and his wife are due the day after we are, also with their first kid, family conversation often orbited around pregnancy and babies). A few times, one of Miguel’s aunts asked us what we were planning to do – breast or bottle feed? Disposables or cloth? I usually launched into a pro-breastfeeding argument, letting everyone know we would be doing that, but that we would use disposable diapers, causing to a raised eyebrow or two at the mention of disposables.
At one family meal, Tía Lea started talking about the benefits of diapers for babies. Without specifying, she said that one kind of diaper is “unsanitary,” “bad for the baby,” and otherwise just bad for the health of the baby and the family in general.

I assumed that she meant cotton diapers. I was wrong. She looked at me after I said this, and said no, disposable diapers were the ones that were unsanitary because they often get thrown in the street and are hard to dispose of, so waste accumulates in your house. Furthermore, with disposables she thinks that babies don’t learn when they are wet so toilet training is harder, they get more diaper rash, and are exposed to all sorts of absorbent chemicals, meaning they sit in their waste longer than they otherwise would. All of these factors, to her, are bad for the baby and bad for the family, since the baby isn’t learning what it should when it should. To say nothing of the added expense of buying disposables, which to her is bad for the family budget and inconvenient. Most of the family members there — including her son, who had just completed a rotation in obstetrics — agreed with her.

This rattled my preconceptions, to say the least. After returning to the U.S., Miguel brought up the diaper debate again. He said in his family they’ve always used cotton diapers, even after they moved to the U.S., so he’s very comfortable with how to fold them properly so they don’t leak, how to clean them, and so on. I then did some poking around online, and found impassioned arguments for cloth diapers, as well as plenty of families saying that disposables work fine for them. But it seems that the simple diaper + diaper pins of our infancy have been improved upon. Now there are snug, breathable and washable covers that ensure you fold them accurately and reduce leakage, flushable liners that helps reduce clean-up, even “starter packs” that come with everything you’d need (see http://www.bummis.com).

The point here is that the attitudes I ran into in Bolivia about something as ubiquitous & pedestrian as diapers flags something profound regarding orientations towards what “convienence” or “sanitary” means, to say nothing of our responsibilities as family members, parents, and perhaps even global citizens. Here in the U.S., we are often told that disposables are better, more sanitary, and more convenient, just as we are similarly convinced of the benefits of bottled water, for instance. What does this say about our attitudes towards “convenience”? Are we too short-sited environmentally? Can we rework our ideas of what is “convenient” to better incorporate factors like the impact on a very local enviroment (i.e. your home), your baby’s perceptions and development, and so forth? It seems that a big problem contributing to the disproportionate environmental impact per U.S. inhabitant is precisely this short-sighted, immediate-gratification, and, most notably, individualistic definition of convenience. But taking Lea’s (as well as many other relatives I spoke to) attitudes towards diapers into account means that we need to understand the plurality of ways that “convenience” “sanitary” and “benefit” can be defined.

PS: We’ve decided we’ll give cloth diapers a shot, at least at first. We might combine with disposables, especially while visiting friends or family for a weekend, but the arguments for using cloth (at least sometimes) are convincing.