Bolivia

When I got off the plane in La Paz, my chest felt the same sensation it had 3 years ago. We had just landed at 13,325 feet, and I could tell that there was less oxygen in the air. It was my second time in Bolivia, one of the only international locations I’ve been able to return to more than once, and thus there was an odd sense of familiarity when we landed—the same majestic, white-capped mountains illuminated by the morning sun, the same outside walk from the plane to Immigration, the same dark olive green uniforms worn by the immigration officers.

Ultimately, however, while many of the sights and sounds reminded me of my stay in Cochabamba, Bolivia a few years ago, I truly enjoyed getting to know new cities. Each one has a distinct character. La Paz is an eclectic mix of the traditional and modern, with 'cholitas' in bowler hats, colorful skirts, and shawls, alongside people in suits and ties, or name brand clothing. In order to cross the street, we learned to dart in between minibuses and taxis, and quickly realized that a red light is more of a suggestion than a requirement. Santa Cruz, in contrast, has a far more relaxed pace. There are no high rises or crowded streets as one might expect to see in the 'economic powerhouse' of Bolivia. It is also not the 'plastic city' that our teachers and host families in La Paz warned us about before we left. Palacios, the small rural village where the clinic was, consists of a few small houses, a store, and the clinic, which is essentially where the road ends.

Munasim Kullakita "Love Yourself, Little Sister"

In La Paz, each morning, we had Spanish class from 9 am- 1 pm, and then return to our host family's home for lunch. In the afternoons, we were able to volunteer four times with a local organization called Munasim Kullakita, or 'Love yourself, Little Sister' in the Aymara language, that works with girls who live on the street and have been victims of sex exploitation and trafficking. The organization runs two houses for these girls. The girls begin/ return to school, and also learn skills such as knitting so that they can eventually gain independence. The second part of the organization's mission is outreach. They have 'recruiters' who continue to go out and build relationships with the girls who are still living in the streets. They encourage them to take care of themselves, remind them of activities that the organization has three times a week, and notify them of days when they can get medical attention and/or a hot shower.

The second time that I went, Alicia and I walked around the streets with one of the organization workers. He told us there were three rules that we had to follow when we were with him: 1.) Don't carry any valuables or money on your person. 2.) Don't let yourself be pulled away from the group. 3.) Wash your hands thoroughly when you return. With those admonishments, I was nervous about how we would be received as foreigners, and did not know what to expect.

Initially, as we walked the streets with the organization worker, I actually couldn't tell which girls were living on the street until they flocked over to the worker to say hello. Most of them were high on some sort of toner, paint thinner, or nail polish remover, I’m not sure which. They would pour some on a ball of wool or yarn, and bring it up to their faces to inhale, all while talking with us. It was difficult to hold a conversation with them, and when they kissed us on the cheek in farewell, the odor was overwhelming. According to the organization worker, one of the largest barriers for the girls to leave the streets is their addiction to drugs.

While we were standing with one group, a girl stumbled out into the street, sat on the edge of the sidewalk and began wailing, her cries echoing down the street. The organization worker tried to see if he knew her by calling out to her and asking what her name was, but she would not respond; and none of the other girls seemed to recognize her. He told us that it would be better if we did not approach her since we were not sure how she would react. I looked back at her as we were walking away, and the image of her was burned into my memory-- her slight, hunched figure sitting on the sidewalk made no more than a silhouette by the bright sun. By the end of our experience that day, I grew to appreciate how much progress each of the girls in the house had made after leaving the street.

Trans Copacabana

Before we left for Bolivia, we were warned that we would have to take a 10 hour overnight bus ride to Santa Cruz from La Paz to meet up with the rest of the team. Little did we know at the time that, that number would continue to grow as we talked to people in La Paz. By the time we left for Santa Cruz, the number had grown from 10 to 15... to 17, until one kind woman told us that we should be prepared for 19 hours on the bus. Ultimately, our bus ride on the Trans Copacabana bus line was not as bad as it could have been, but it was certainly not one that I would necessarily want to repeat in the near future. Due to our fear of the bus bathrooms, none of us dared to try the bathroom even after more than 12 hours on the bus. Only when we stopped at a checkpoint the following morning did we venture outside to pay a couple bolivianos to use some squatting toilets in a small hut by the side of the road.

El Centro Medico Humberto Parra

In the clinic, the patients we served could be categorized into three groups. First, there were the patients we could help immediately. These were the ones who came in for medication refills, parasite treatment, UTIs, and other manageable illnesses. On the other end of the spectrum, there were the patients who had more life-threatening illnesses such as patients who needed a pacemaker or radiation treatment. In those cases, the clinic was able to write referrals. Although the cases would then have to be sent for approval, there was a good chance that the patient would be able to receive a life-changing treatment. The most difficult cases for me were the cases in between where we didn’t have enough resources to make a definitive diagnosis, but the patients’ quality of life was not affected enough such that a referral to a specialist would be approved. It was frustrating that we could not offer any assistance, and that they would likely return to the clinic with the same symptoms over and over again. At the same time, I did find it rewarding to be part of the continuity of care for many patients with hypertension and diabetes. It was encouraging to know that they would continue to have access to care even after we were gone.

“Usted tiene Cancer”

In PCM-1, we learned how we should give patients bad news. We learned that it is important how you deliver the message, that we should be sensitive to the patient. However, my Spanish capabilities never felt more inadequate than when we had to deliver bad news at the clinic. How do you tell an 18 year-old girl with an 11-month old baby that’s she pregnant again when you’re not sure whether or not she wants another baby? How do you tell someone that they need a pacemaker because their heart might go into ventricular fibrillation at any moment? How can you explain to someone that they have cancer when all the words you know seem equally harsh, or scientific?

The patient came in with lab results from a hospital in Cochabamba for ‘follow up’ because she was still hemorrhaging. The lab results stated that she had cervical cancer, but no one had told her. I was working with Alicia that day, and when we went out in the hallway, we tried to plan how we would tell her. It was all for naught, however, because when we walked back into the room with the clinic coordinator and physician to explain the situation, the coordinator walked in and said, “Usted tiene cancer.” Just like that. I remember looking over at Alicia, both of us horrified, but it could not be undone.

My time in Bolivia demonstrated how easy it could be to become complacent by treating each patient with a cookie cutter method of counseling, and simply writing a prescription rather than addressing the root of the problem; however, I also learned how vital it is to remain vigilant, to treat the individual, and to give the patient a space to share their distress and pain, even when we, as medical care providers, might not be able to provide a treatment. In the end, it is the kindness and compassion that we show that is remembered.