Privileged Providers

When we think about healthcare in the developing world, we tend to think about how difficult it would be to live without access to care. We think of the sorrow we would feel at not being able to vaccinate our children, the fear of a mother about to deliver her baby and the constant social oppression of acute, preventable illnesses. My time in Bolivia taught me the unexpected lesson of how difficult it is to live in the developing world as a physician without the resources to administer care.

My first glimpse of this, though I didn’t process it until much later, was with my host family in Cochabamba. My “papa” was a physician, now working as a director of a pretty nice hospital. He came home exhausted one day and told me about a fiasco he had to deal with at work: theft. Sure, we occasionally hear about a patient having his cell phone stolen, or her clothes left behind in the ER, but this theft was different. Somebody stole a pacemaker. A patient was scheduled to have it placed that day and as the nurse comforted him she set it down momentarily, and when she turned around it was gone. After shutting down the floor and interrogating everybody inside, they did find the culprit. “But where would you sell a pacemaker?” I asked. The response was something like, “well, anywhere... la Cancha.” La Cancha is the name of the enormously crowded street market where you can find just about anything from fried pigs’ feet to live chickens to car parts to, well, pacemakers I guess. It was no surprise to them. My feeling of amazement would be greatly compounded in Santa Cruz when we heard of a hospital’s ultrasound and CAT scanner being stolen. Where do you sell a CAT scanner?

la Cancha

Before beginning our work at the clinic we visited a hospital in Santa Cruz. We even got to go on morning rounds. It was fun to see the similarities: doctors pimping the students, students quickly answering with a wince of uncertainty, coffee breaks and sneaked text messages. Of course there were major differences as well. Patients have to pay for everything before it happens, for example, so if a resident orders a set of antibiotics to be delivered through an IV, the family must take the orders to the pharmacy and purchase the drugs, the IV bag and the needle before they can give it to the patient. This means the residents often end up shelling out a few bucks to help their patients. Everybody who comes to this hospital is poor. We were there with a Loyola pediatrician, so we got to see the pediatric floor. A Bolivian physician was actually quite happy to show us around, and I was impressed by the fact that I had yet to feel like an inconvenience, a common feeling for a student in a busy hospital. We came to a row of infants and it began to sink in just how much this place is struggling. A tiny, pale baby was using every effort to breathe and Dr. Stirling said he would have put him on a respirator a long time ago if we were at home. This hospital, however, has only one breathing machine and another baby was using it. Every time a new baby is born or arrives in respiratory distress they have to make a very difficult decision.

We all walked to a small conference room and one of the students translated for Dr. Stirling. The Bolivian doctor wanted to know if he thinks they’re doing okay. “I have very limited resources, but I try to make the most of them. Still, I worry that I am not providing adequate care. What do you think?” His face was full of earnest, like that of a student looking to his teacher for approval. I have never seen a physician humble himself so much in a professional setting, in front of another physician and a handful of students. His posture told the story of a daily internal conflict, a fear of shortfall and the desire to practice as the doctor he was trained to be. He knew what resources we had and he knew how to use them, he just didn’t have them.

People who enter medical school may be characterized in a number of ways – type A, obsessive compulsive, having a god-complex, perfectionists, etc. – all of which boil down to wanting to be in control. As future physicians we have been warned not to allow ourselves to feel overly guilt-ridden when we are not able to save a patient. This is undoubtedly something we will all face, more or less frequently depending on which field of medicine we choose to go into. It will be difficult but we will learn to accept that it is part of the learning process and that Life and Death are really in somebody else’s hands. Doctors in developing areas of the world must be faced with these feelings more often, and they have the additional hurdle to jump of knowing that something could be controlled if only they had ________. You can fill in the blank with just about anything.

From that point on I continued to see examples of doctors making the best of what was available. I was impressed by their ingenuity and constant awareness of resource allocation. In this sense we, i.e. incredibly privileged students, have a lot to learn from these residents and doctors. They have a set of skills that we don’t use on a daily basis and they approach medicine with a level of creativity and practical caution that may become necessary for us all. I feel incredibly fortunate to live in a country where not only do I have access to health care, but I will be able to practice medicine in a country where I will have all the resources necessary to provide a high level of care

Team Bolivia: Mission Statement

To serve and learn from the Bolivian people, local communities, and current clinic staff in such a way that results in enhanced health, improved care systems and lasting health education for all involved. Also, to ensure that the experience has a continued impact on our own lives, not simply affecting us for the two weeks in which we serve, but rather for the full duration of our professional lifetimes.

To Trace a Path

I was fortunate enough to go to the Philippines between my third and fourth year of medical school through the GHF program. My contact there was mys sister, who has lived in Sorsogan for the last year. Sorsogan is a southern province in the Bicol region on the same island as Manila, and the word means "to trace a path." She works for Innovations in Poverty Action on a micro finance and migration project. She was able to put me in touch with a family medicine physician who was also a tuberculosis specialist at a local hospital, and I worked there from 8AM-6PM almost every day of my visit.

Here's an excerpt from my journal that I wrote on 6/17/11:

"I had my first day at the Sorsogan MMG Hospital (pictured) yesterday where I'm working with Dr. Nancy Labarete (also pictured). It's a private hospital but they have a public multi-drug resistance tuberculosis clinic that is funded by Global Fund. People from all over the province come to get free medicine there through the directly observed therapy, or DOTS program. It was so sad to see so many sick and emaciated people and a little scary to be around such a contagious disease even though I was wearing a mask. I never realized how difficult second-line TB medications are to tolerate, or the serious side effects they have. For example, many patients come in cachectic, but it's almost impossible to help them gain weight because the daily medication makes them vomit excessively. As heartbreaking as this was, I was still so inspired by the people I met there, from patients to physicians to nurses. The were all so accommodating and invested in my learning, which is a rare thing when a student visitor is almost just passing through an already under-staffed hospital. I was actually told I was the first American medical student they'd ever had, and they worked hard to help me have a worthwhile experience, and to try and convince me to come back! I'm sitting in my sister's office right now to write this entry, then I'm grabbing a tricycle (a motorcycle with a sidecar for the passenger, which is how everyone travels) to the hospital in a few minutes for my second day, where I was told I would help run the E.R. Rather nervous about this, game face!"

Needless to say, I survived helping out in the E.R. and I went on to see multiple surgeries and procedures, as well as to continue to interview and get to know the MDR TB patients. I absolutely plan on going back someday, so I can try and return the favor of shared kindess and knowledge through extremely trying and impoverished circumstances. To the Filipino people I met- Salamatpo!