Cuba cuba!

Tomorrow am heading to Valle Grande for the 2nd International Che Cuevara Meeting. Dont know anything about him so going to have to do some reading as the people I´m going with worship him almost religiously! Should be interesting to learn a bit more about Cuban history and politics though, and Che´s time in Bolivia. Turns out that the soldier who killed Che had cataracts removed for free by the Cuban ophtalmologists who are working here! The whole issue of Cuban doctors in Bolivia is really complicated and controversial; I think I mentioned it earlier, but here´s a more in depth summary.....

The Cuban doctors in the hospital have been here since May 2006. They brought with them an X-ray machine, lab equipment and technicians, ultrasound, endoscopy, ECGs, equipment for theatres, a 6 bed intensive care unit, a team of well equipped ophthalmologists and lots of medicines, all of which are free of charge for Bolivian patients, who would otherwise have to pay for treatment which they cant afford. This is all paid for by the Cuban government, and without this help the hospital would be without many vital services (eg when the Cuban anaesthetist went on holiday there was no surgery for two weeks). The Cubans are good doctors and treat their patients much better than their Bolivian counterparts, probably because they have chosen to come here, a bit like people in the uK choose to volunteer with Medecins Sans Frontiers. They are really popular amongst patients in the country, but in more middle class urban areas people question whether they are in fact doctors at all!

Sounds great, but there are quite a few problems. Firstly, the hospital seems to be divided into two systems, the Cuban system and the Bolivian system - there are two laboratories, two pharmacies, two sets of patients notes, two teams on call at night. Patients choose which service they want to use - not surprisingly many choose the Cubans. This leads to several problems - the hospital is losing money which before it recieved from charging patients - and this means they cant employ the much needed social worker or secretary. Secondly, some of the Bolivian doctors now have very little work to do, and so feel demoralised and unwanted. Thirdly, the two teams dont work together as well as they could (both sides say that the other side isnt willing) and by duplicating everything they are wasting time and resources. And what will happen when the Cubans leave? (no-one knows if a new team will arrive when these guys leave in May 2008). They arent training any Bolivians to fill the gaps when they leave.

All in all, it seems to me a bit like a bad MSF project, with all the downfalls that people have pointed out in the past with many western NGOs - little thought for sustainability or long term effects, too much focus on equipment and medicines rather than management and training for the future, and poor co-ordination with existing local systems. In fact, thousands of Bolivian doctors across the country are unemployed - ´why do we need Cuban doctors here?´ they ask (though whether they would go and work in the remote areas where the cuban doctors are is another question).

Contrast all this with the work of Medicus Mundi, a Spanish NGO which is helping the hospital with training and support in administration, quality control, self assessment and hospital management. They seem to be doing good job but with many obstacles, lots of personal issues seem to get in the way of progress here, very frustrating. The focus seems to be on getting the hospital acredited as an offical secondary care establishment. Maybe a bit misfocused though as there doesnt seem to be any primary care here in the town, which would be the logical place to start, and a good place to send the Cubans too, who come from possibly the best primary care system in the world!

So, interesting to see the different forms of international aid - I think that things would be worse without the Cubans, but there´s a lot of room for imporvement.

Carnival.....!

The Jungle

So I´m in my last week of ´work´ here in Bolivia. Am looking forward to being free to travel around a bit, am planning to go to the 40th Anniversary of the Death/murder of Erensto Che Guevara in Vallegrande where he was killed, which will be interesting, and then some other places in Bolivia.

The last few weeks have been up and down, I was getting quite fed up of the hospital so was really good to be able to escape to jungle for last week. One of the doctors here is doing a residency in Family, Community and Intercultural Health, a new program started by the current government, which sends doctors out to remote communities, to work with the community in health promotion, public health and community development, as well as attending day to day health problems. Its really interesting and I think it confirmed for me that thats the kind of thing I want to do in the future... The best bit was 3 days of trekking and canoeing in the jungle to visit 3 indigenous communities where the doctor and nurse vaccinated children and gave talks to the communities, as well as talking to local leaders to plan activities for the future. In one community we met the founder of the village, who chose the site and settled there with 80 people. If you´ve read 100 Years of Solitude, it really reminded me of that. The people were very friendly but also wary, I think they have been let down by a lot of people in the past so its not easy to win their trust. They live in a National Park, in virgin rainforest alongside rivers full of fish, which they live off along with the crops they grow. Recently, the influx of people from other parts of Bolivia to the area, to grow coca, has put lots of pressure on them. It was really interesting to talk to them, unfortunately I couldnt stay longer. It was the best thing I´ve done so far.

I´ve got 2 more days in the hospital, and then I go back to Cochabamba to see my supervisor, and then I´m free! I´m looking forward to having some time off and also maybe seeing some gringos, I havent mixed with many and sometimes its been a bit lonely I think. Also looking forward to coming back to Bristol, seeing friends and family and (surprisingly) learning some medicine, have realised here how important it can be.....

Patients and patience

Aaargghhh, just wrote loads and then lost it.... ANyway, in summary, 2 weeks in Villa Tunari, lots of patients, interesting cases, and a bit of frusttration with the system here, it takes ages to get anything done because thiungs are disorganised and sometimes people are lazy. Has had some serious and sad consequences for a few of the patients I´ve seen. I dont feel there´s much I can do to improve that, just have to bite my tongue and be patient, but hopefully I´m learning for the future. Medicus Mundi are involved in the hospital management with a project trying to imporve the organisational side of things.

For those medically minded, some interesting cases: abscess caused by human bite on foot, congenital (hopefully - if not congenital then not worth thinking about.....) neurosyphylis in a 7 year old, snake bites treated by local remedies (put flesh of dead snake on wound, put babies poo on wound!), hemoglobin of 2 in a 15 year old, and some amazingly impressive parasites (see picture - those were in a 8 yr old boy, you could feel the lump in his stomach and he cried like he was giving birth, not surprisingly...!)

Interesting to talk to the team of cuban doctors workign here, all paid for by the cuban government, in solidarity (or will Fidel ask for some Bolivian gas in return?). They have had an impact here and the aptients really like them as they give free treatment. Lots of rumours in middle class doctor circles about their poor treatment and how the Bolivian govt is paying for them, thuis robbing Bolivian Drs of jobs. Not true.... But shows level of oppostion to Evo and the things that he does in some circles. People in the countryside still really like him, there has been more investment in education, more health posts, and more health workers (even when you dont include the Cubans) and an agricultural bank which gives low interest loans with repayments on an annual basis - easier than monthly if you depend on seasonal crops.... But there are people here who are angry with Evo for not doing enough for them.

I was hoping to meet him yesterday, we were sent to provide first aid at a football match he was supposed to be attending, I took my camera all ready but in true Bolivian style he got delayed and didnt make it before a huge storm put an end to proceedings. Apparently hes back in 2 weeks so I may have another chance, he comes from a village 2 hours away from here, its strange to think that when we treat a young boy/man from that village who smells of coca leaves and sweat, and says he works on a chaco (plot of land), that was Evo 2o years ago.

Have been able to get into the community which has been interesting, talking to ladies and vacinating (I always seem to end up vaccinating dogs, the biggest and fiercest so far was aptly called Pinochet!) and then finishiung early and gong for swims in the river! Fun but would be good to use that time to do some health promotion talks, no-one knows about AIDS although here the rate is higher than most of Bolivia, and with it being a stop off point for truck drivers from Argentina and other aprts of Bolivia, its an important issue. However, few of the other interns seem interested in that kind of thing.

Have also been out a few times with the interns here, and some spanish volunteers in a nearby town, which has been fun. And playing in goal for the hospital 5 a side football team - let in 9 goals last match which was a bit depressing!

So thats it for now, I think Ive reached half way of my time in Bolivia, am really pleased to be here, I think I´m learning that in the end us people deep down are all the same everywhere, and with a bit of patience we can understand each other... if only it was that simple!

A quick catch up and up date

Have realised that there are lots of things that I meant to put on here and havent got round to and its getting later and later... so a quick summary:

The last few weeks in Cochabamba hae been good if a bit quiet, the hospital was interesting but quite slow, some of the highlights were the trips in the community to vaccinate dogs and do interviews with ladies about maternal health and why they dont go to hospital (my husband wont let me, its too far, I´m scared, the doctors dont respect us). Also met a Dr who works in the Dept of Publich Health in the University, and is co-ordinator of the governments family and intercultural health program in Cochabamba. I asked him what he thought about why ladies here dont use family planning - his eyes lit up and he started this long talk about how family planning in Bolivia wasnt necessary as they arent overpopulated, and family planning is a neoliberal imperialistic plan by the US and UN to kill poor Bolivians - a form of genocide. Only once people are educated should they use family planning he said. It was weird, I really dont understand the reasons for thinking like that, unless its a reaction to previous sterilisaiton programs in Bolivia which I think happened with support of donor agencies.....

Other highlights out of hospital - dressing up and dancing in a local carnival (sorry I cant upload photos!), eating lots of meat, fruit, bolivian pasties, visiting a prison where the prisoners are free to organise there own community within the walls, interesting but also scary to think how the hierarchies of power are reached and maintained...

We also got invited by the secretary for health of the local council to a small community meeting on the outskirts of town which was really intersting - the secretary is going to visit lots of these meetings and do health workshops as well as try to find out what the community thinks about the hospital. She is a very cool lady and in the end I wished I could stay and help her.

So thats more or less it for Cochabamba, I´ve moved to Villa Tunari in the Chapare, region of coca growers and Evo Morales stronghold! Its been interesting, I arrived yesterday and was told that the timetable was 7-5 with 2 hours for lunch, and I would have a 4 week placement in Emergencias with no days off, every 4th night on call (starting last night - 1 suicide attempt with fertilizer, 2 stillbirths, 1 normal birth, a 2yr old with pneumonia and probable sepsis, a stabbing) - its been quite hardcore but also quite amazing, the people are so intersting and different, but I really really want to get out into the jungle and see the communitites and swim in rivers and see blind birds in caves and eat fish and do loads of stuff. Hopefully will be able to escape at some point! But my Spanish is getting batter, I can communicate better with patients and today felt a bit more comfortable in the hospital - up to now Ive been quite scared/nervous about dealing with patients.

Very quickly....

5 minutes before gynae clinic starts. I can see that I need to imporve my blogging skills. So far hopsital has been good if a bit quiet, I´ve been in the community lots vaccinating dogs against rabies, visiting ´high security´´ prisons, talking to ladies about the husbands who beat them, their kids, vaccinations.... Its been interesting and sometimes a bit tough...

Im staying with a family who are friends of my parents, they are really nice and looking after me very well. Am trying to do a small study about maternal health in the hospital but its not really working very well... Nest week I start in a busier hospital in a town in jungle, not sure if I´m ready yet but going to have to be! Got to rush, more later....

Bolivia

My first report from Bolivia, and first attempt at blogging. Its been 2 weeks since I arrived in South America, and so far so good. Haven´t died, been ill, robbed, kidnapped and am enjoying it! At the moment I´m in Cochabamba, in a small community hospital where I´m doing obstetrics and gynaecology, some paediatrics, and some community work. The hospital is quite quiet and there are lots of Bolivian medical students who are all very friendly. It means its been quite a relaxing start which is good. More about that in the future...

For now, a bit about the country. I´ve never been anywhere so politicised in my life. Evo Morales has brought out very strong feelings across the board, EVERYONE has an opinion about politics. And so varied. Thios was expressed very well yesterday by two things, the fight in Congress in the picture above, and the taxi driver who told me that he wanted a military coup so that all the ´damned campesinos´ (peasants) would go back to work in the fields. Its hard to know who to believe or what to think - is Evo a power hungry dictator in waiting or does he really have the poorest parts of society at heart, and if he does does he have the skills to help them? All in all, its a really interesting situation, I hope it doesnt degenerate and that I can learn something from it.....