More medical reflections, and the real Salar.

This is the end of Bolivia.

It's been a good eight weeks - interesting to see a different way of practicing medicine in the hospital, fun to improve my spanish a lot, exciting to be able to travel around the country seeing some amazing things, and memorable for meeting engaging and interesting people..

Some more thoughts on medicine here;

There is a strange kind of 'caste' system in Bolivia. The country is almost frozen in between the typical way of life which has been lived out for centuries, and trying to modernize into a country able to interact with the world on a global level. Because of this there are two types of people here - the people from the 'campo' (countryside), who are more traditional folk, and then the more modernized urban people. The 'campesinos' dress in traditional multi-coloured clothing, work the land all day, are missing most of their teeth following a lifetime of sugary food and dentist avoidance, and they often speak only quechua or aymara (two tribal languages here). By contrast the urban people dress in American clothing, drive cars or motorbikes and will speak Spanish with the occasional English word. Obviously this is a big generalisation, and a majority of people are somewhere in between.

When different people come to the hospital it can be quite sad to see the way in which they are treated. Most of the doctors come from the 'urbanized' people, and unfortunately they can have a certain amount of pride and self-importance in the work that they do. When the campesinos come in to see the doctor it seems like they are treated with even less respect that usual; as if they don't understand what's happening, and as if "they should just be quiet and listen to the doctor who knows best". I'm not sure whether I have been influenced by the doctors views, or whether it really is the case - but it does seem like they lack understanding. Often they will come in and simply tell the doctor what is wrong, then ask them for a pill to make it better; there is no exchanging of information, listening to questions or advice, or accepting any solution other than a magic medication. It seems like it can be hard for both sides - the doctor feels like the patient isn't understanding and won't cooperate with any treatment or advice, and the patient feels like the doctor is holding back the medication which could so easily make all their illnesses better.

There are definitely benefits to the healthcare here compared to home as well. Patients don't need to be referred to a specialist and then be kept waiting for months. They turn up to the hospital at 7am, ask to see whichever doctor they think they need, and then sit and wait until they're seen (usually by 11 or 12). If the doctor decides that they need an x-ray or other investigation then they send them off down the corridor to get it, and then bring the results straight back to them. If any follow-up is needed then they'll tell the patient to drop in again in a couple of days. One morning I was in a consultation with a traumatologist. His last patient had a fractured wrist which had been badly repaired. The doctor happened to be driving into town after his surgery, so he offered to take the patient and her mother into the city where he could operate to fix her hand before he had lunch. I can't see that happening at home!

Away from the hospital - this is my 'holiday' week in Bolivia. And we finally made it to the salt flats!

Our mode of transport for three days at the Salar de Uyuni.

Probably Bolivia’s most famous tourist attraction; it’s around 4,000 square miles of salt, going down 150m deep. I think it’s the largest deposit of salt in the world. If that wasn’t enough excitement, then the surrounding area was also where Quantum of Solace (007) was filmed. Wow.

Salt flats.

The five volunteers at the hospital.

We arrived in Uyuni late in the day on Friday, after a bus and train combo down through Bolivia, and started our tour on Saturday morning. The classic tour is 3 days and 2 nights, although because it’s so popular then everything you see is packed with other 4WD cars and gringos wearing ridiculous alpaca hats and taking photos of everything, just like me. This couldn’t really be helped though, so we tried to just ignore the crowds and enjoy the scenery.

Salt piles ready to be eaten.

Isla del pescado - hundreds of cacti
in the middle of all the salt.

Day one was the only day on the actual salt flats (Salar). We visited the town where they process the salt, and then onto the salt flats – driving for an hour or two on a completely straight line, without seeming to move anywhere since our only point of reference was the distant mountains on the periphery of the salt. We stopped for lunch in the middle of the white expanse; some barbecued llama. Then was the chance to take some photos of the area – all sorts of bizarre photo opportunities since perspective is completely confused on the salt.

Some cacti as high as 10m.
All very spiky.

Sunset on the salt from the roof of
our car.

After lunch we visited the Isla del Pescado – an island in the middle of the salt (originally the salt was a sea, which then evaporated to leave all the salt..). The island was full of gigantic cacti – up to 10m high. Amazing to see such huge plants growing in the middle of a seemingly uninhabitable environment – apparently it takes 3 years of no rain to kill them off. The first day ended with watching the sun set over the salt, then driving another hour to a salt hotel – a building made completely out of salt. It was surprisingly warm (once the sun goes down here the temperature plummets. Our whole weekend was spent between 3669 and 5000m above sea level, so in the dark we needed as many layers as possible, whereas during the daytime we were sweating in the car, and applying factor 30 regularly).

Day two was spent off the salt. We started by visiting some volcanic rocks, which was like a giant playground. It's funny how in the UK if you visit historic geographical wonders or precious tourist attractions the chances are you'll be forced to look at it from a distance, behind a rope, whereas here we were positively encouraged to go climbing over everything.

Flamingoes on the lagoon.

'Flamingo' pose.

After the rocks we drove past 5 lagoons - each one filled with various flamingoes. They're funny to watch - they just stand there on one leg, which looks like it isn't strong enough to support anything, let alone a fully grown penguin.

After lunch we moved on to some more giant rocks. This time the main attraction was a 'rock tree', which was a rock that looked like a tree. Surprisingly we weren't allowed to climb on this one, but we did enjoy climbing all over the rocks around it.

The 'rock tree'. A rock shaped by the
wind over the decades..

The 'coloured lagoon'. Red because of
the algae and vitamins and things.
This is also why flamingoes are reddish.

After this we went to a larger lagoon known as the laguna colorada - 'coloured lagoon'. This was a strange red colour, apparently because of the different algae and vitamins and things that are in the water. The flamingoes eat from this lake, and apparently that's why flamingoes are pink! Fascinating. It looked a little bit like a giant lake of tomato soup. I didn't try any so can't confirm or deny that.

The evening was spent in another hotel, shivering away trying to absorb all the warmth from cups of tea, until we finally went to bed at the healthy time of 9pm.

The natural hot springs, 7am.

The geysers going full steam.

Day three began at 4.30am, in order to maximise the day. We started off by visiting some geysers as the sun came up - big natural jets of steam flowing out of the earth. Even better though was the hot springs that came afterwards. It was fantastic to sink into some hot water and escape the cold air. The ground surrounding the pool was still covered in little slivers of ice from the night before, and getting out again in order to get changed was not pleasant!
By now we were right down in the south west corner of Bolivia, on the border with Chile. The rest of the day was mainly a drive back up to Uyuni, enjoying the scenery and the occasional herd of llamas strolling by.

We arrived in Uyuni in the early evening, before getting another overnight train up north again. This wouldn't be Bolivia if there wasn't a strike involved, and we had to spend the day in Oruro before being able to catch a bus home to Cochabamba that evening. Tremendous experience.

The end of Bolivia.

I'm off to La Paz shortly, where I'll spend a few days before flying to Miami early Saturday morning on the first leg of the journey home.. It's been good Bolivia, hasta luego.

Medical Reflections and Dinosaur Tracking

Medicine in Bolivia.

Over the last seven and a half weeks I've been trying to recognise the differences in health care between the UK (one of the most advanced health care systems) and Bolivia (one of the most impoverished nations).

Medical Students
Students undertake five years of studying here, as in the UK. There is a large proportion of students from other South American countries as well; Bolivia is the cheapest country in the continent and so a lot of Brazilians and Peruvians come over to study. The system allows transfer throughout South America at any point, so they can transfer home just before they finish studying and then work there once they graduate. A lot of Brazilians are here just now; understanding their mixture of Spanish and Portuguese can be a struggle!
Once they finish their five years they work for one year as an intern (seemingly similiar to FY doctors in the UK). This year seems horrible - they work unpaid (in fact they have to pay to do it!) and rotate around different hospitals. Every third day they work from 7am until 2pm the next day (30 hour shifts) and the other two days they work 7-5. They have no holidays and can get 'punished' by the doctors here. One intern went to buy a new pencil without telling anyone and was made to work an extra five hours at the end of his shift!

The way of learning here is completely different as well. Students turn up at their clinic, and 4 or 5 of them will crowd into the room. The doctor sits behind his desk while the students stand crowding around him like little sparrows in their oversized white coats. The patient enters and sits nervously in front of the doctor, who speaks brusquely at them for a few minutes, sometimes scribbling down a prescription, glancing vaguely at an x-ray or looking distinctly bored. The students are rarely spoken to while the patient is there and seem to only learn by trying to read whatever the doctor is writing down, and copying it down themselves in little notebooks. I guess it encourages students to be more proactive in learning in their own free time, but it's not a welcoming learning environment!

Doctor-Patient care
While here I watched the film 'Patch Adams'. It shows the American health care system from a few decades ago, and how the patients are treated as 'diseases' rather than as people. It's amazing how much of a resemblance that has here!
The doctors will often not acknowledge the patient when they enter the room, they can be impatient with them and brusque with them, and never ask them about their quality of life, or how their illness is affecting them!
Patients are never referred to by their name, and on ward rounds one of the interns will present the patient to the doctor while 7 interns, 6 nurses, 4 doctors and myself all crowd round the bed. The patient themselves aren't consulted, to the extent that it almost seems unnecessary to have the discussion with them present!

Hospital Procedures
As a proud holder of qualifications in cleanliness champions and patient manual handling, I am disappointed in the standards here. Doctors usually wash their hands on average once a day, and then only with water. Each consulting room has had the same sheet on the bed for the last 7 weeks and alcohol gel hasn't yet made an appearance.
We had to move a patient from the ward to the x-rays once who was too frail to walk herself but for some still unknown reason was too sore to sit in a wheelchair! Two of us took her - each one grabbing hold of an arm while a nurse trailed behind holding her catheter bag. It was a good thing she didn't fall since I think the only thing we could have done was fall on top of her.

Many differences in healthcare!

Torotoro - 'straight out of the
National Geographic'.

Dinosaur Tracking

At the weekend we headed South for 5 hours, to Torotoro national park. It's a hidden gem of Bolivia - full of amazing natural wonder and historic marvels.

The park itself is a vast expanse of rocky hills, echoey caves and deep ravines - ugly big cracks in the surface of the earth. It's most famous for being the home of several prehistoric fossilized dinosaur footprints, and with a bit of imagination you could picture velociraptors and stegosauruses running riot in the mountains here.

Our transport on day one -
an hours ride in the back of a
pick-up, past enormous
rocks towering over us.

One of many stone formations. Here
we are riding 'the tortoise'.

We spent the first day walking through the hillside, past gigantic rocks and clambering into ravines and up cliffs.

You are required to take a guide with you whenever you leave the town of torotoro to enter the surrounding park, who takes great pleasure in pointing out all the different ways you can see dinosaurs - rocks, gaps in rocks, clouds..

Our group enjoying the view.

The hard hat was the best
use of 7Bolivianos so far,
much needed for crawling
under stalactites.

Standard 'jumping' photograph
to celebrate leaving the caves.

In the afternoon of day one we went to a series of caves hollowed out over the years by a river. We spent a couple of house climbing through them with hard hats and head torches, getting hot and muddy.

We were able to go 800m into the caves which have been hollowed out over the years. It was amazing to be able to roam through stalactites and stalagmites, sliding down little slopes, crawling through holes we shouldn't have been able to fit through and getting completely disorientated trying to figure out which way to wriggle next.

A set of carnivorous footprints.

A herbivorous giant.

On day two we took a walk with our new guide - Jesus. This started off by tracing the steps of dinosaurs.
Hundreds of different trails of fossilized dinosaur footprints are trapped in the hillside. Some say the tracks were made in lava as the dinosaurs tried to flee from a volcano. It's odd to stand in footprints that are thousands of years old!

The rim of the canyon.

The natural plunge pool.

That afternoon we arrived at a canyon, cut out of the ground.
We descended 250m into it, to follow a river bed for half an hour, over huge boulders and along dirt tracks, until we found a little haven after several hours of dusty, sweaty and tiring walking - clear waterfalls to plunge into never felt so good.

Amazing waterfalls.

 A great weekend trip exploring some of the practically undiscovered highlights ov Bolivia. In some ways it's a shame this place isn't better known; there is so much there! But on the other hand, the longer it stays as a remote and rustic secret, relatively cheap to enjoy and away from hoards of tourists, the better!

Alleged dinosaur bones...

Q: What is the capital of Bolivia?

A: Sucre*

Q: What is the only country in the world where there is no MacDonalds?

A: Bolivia**

Sucre is known as the white city, evidenced by this view from the roof of an ex-convent.

Amazing facts right? So we spent the weekend down in Sucre, not eating MacDonalds. It is a 9 hour bus ride south of Cochabamba, slightly higher in altitude but neatly set in a valley. As Rose described the climate there - "Sucre is like a woman right? Always changing.." Of course I disagreed with her.

The declaration of
independence in Sucre.

A giant head of Simon Bolivar,
carved out of one cedar tree.

It is a very interesting city - full of museums about the independence of Bolivia. I got pretty confused, but basically Simon Bolivar (one of the great 'liberators' of South America) went around liberating all sorts of countries from the Spanish - Venezuela, Colombia, Ecuador, Peru.. His intention was to have a unified state - much like a United States of South America. This dream never worked out, but he did succeed in removing the rule of the Spanish. Peru, modern-day Bolivia and parts of Argentina were one country, but under the command of General Sucre, Bolivia gained independence from here in 1825. Bolivar got to name the country after himself, and Sucre got the capital.

Other museums in Sucre recounted about the tradition of masks - there are SO many festivals and parades and parties in Bolivia all the time, at least when there aren't blockades. And there are always masks to be worn - ranging from the humorous elephant or cat masks to more sinister masks depicting the devil and his subordinates. Sadly no photos were allowed.

The view over the rooftops.

We also saw a painting of a virgin from guadalupe who I think is the saint of the cathedral in Sucre? The painting is actually covered all over with precious stones extracted from mines nearby - rubies and diamonds and silver and gold.. Making the picture 'the most expensive virgin in the Americas'. I was distinctly underwhelmed. Luckily no photos were allowed, to maintain the illusion of this amazing painting.

Climbing up to the
top of the bell tower.

One of the best bits of Sucre was all the views. We climbed a hill on the first day to see the white roofs spread out from us, and the second day we entered what used to be a convent and what is now a school. It's an amazing setting for a school! We climbed up to the roof and up the bell towers, and we spent 2 hours sitting up there as the light softened enjoying the peacefulness and the views.

Sun going down on our time in Sucre

It was a good weekend. My only regret was letting that shoe-shine boy shine my shoes. I knew that it was a bad idea to put polish on trainers. I knew it wouldn't work. And I told him that. But he was so persuasive, and I thought - what harm can it do to let a poor boy earn a bit of money..

A little boy sabotaging my
shoes. All for 50p.

We arrived back in Cochabamba at 4.30 on Tuesday morning after another overnight bus that felt like a slow motion roller coaster for 9 hours. We knew we were back in Cochabamba because there was another strike going on and no trufis (minibus buses) were running. Eventually a renegade driver turned up and we all piled in merrily, ready to go home. Fired through the first 10 red lights and then when he saw another blockade up ahead, we of course did a neat three point turn and barreled back down the 3 lane 'motorway', angrily beeping at anyone who dared to be driving up the correct side. After some nifty back roads and dirt tracks we managed to circumvent to blockage and get safely back to the hospital..



*Sucre is the original constitutional capital of Bolivia, where the declaration of independence was signed. La Paz is now the main seat of government and often erroneously considered to be the capital, but is in fact not.

**This fact comes from a local Bolivian friend of a friend, whom I consider to be highly trustworthy. Despite that, this fact may not be entirely factually correct.

How the other side live

Street Dwellers

On Saturday we were given the chance to work with some of the people who live on the streets in Cochabamba. One of the plazas (called San Sebastian) is home to about 20 men and women, who spend every waking and sleeping minute within the plaza.
They are there for various reasons, whether unemployed through alcoholism, kicked out of home at a young age, or in some cases simply born and raised on the streets, so that they know no other home.

Two American girls who we know here go there every Saturday, along with 5 Bolivians from a local church in Cochabamba. As foreigners (I can't believe I still don't pass as a Bolivian) we were strongly warned to stay away from both the plaza San Sebastian and a neighbouring hill where another group have made their home in the shrubland. They are considered to be violent, threatening and offensive by the locals. We were only able to enter safely because we were with people who have put in the time and effort to get to know each of these people by name, although I'm not sure I could say that they have befriended them. We gave out cups of tea and some rolls for breakfast, then tended to any wounds they have (each forearm is criss-crossed with scars, and fresh ones ooze pus and dirt until they can be properly cleaned. I'm not sure how much is self-inflicted and how much results from the regular fights they have amongst themselves). We sit and chat with them and the church group talk to them about Jesus before praying with them and singing some songs.

On other trips into the city we drive past the plaza on the bus, and we can see them lying on the grass, or staggering around drunk early in the morning. But the experience of being in physical contact with them is much more intense and overwhelming.

When we arrived we were instantly surrounded by 4 or 5 of them, each greeting us cordially with a handshake or a kiss on the cheek, like old friends. But from the moment that we met until the moment we left 2 or 3 hours later, each and every one of them held a small plastic bottle in their hand, as constantly and unthinkingly as if it was an extra limb. These small bottles are filled with glue, which they can buy in bulk cheaply. Every couple of minutes they inhale deeply from their bottle, whether they are talking to us, eating a sandwich or listening to a prayer from one of the church members. It was tragic to see how much of a dependence they've built up on their drug - anything to escape the monotony and mundanity of living on the plaza, where their only next goal is to find enough food for the day.

The most upsetting sight for me was to see a 2 year old boy being wheeled around the plaza by his dad, who was so drunk that he was practically using the buggy as a crutch to keep himself upright with one hand, whilst the other held the obligatory glue bottle. I couldn't find out where his mother was, and his clothes were ripped and dirty. He seemed amazingly well considering his surroundings, but the sad realisation is that unless someone intervenes in his life he may well progress onto glue in a few years time, and perpetuate the cycle.

We spent the last hour with the next group up the hill. Another 20 or so people, living on 5 or 6 mattresses and bundles of old blankets huddled under a tarpaulin. Many of them seemed to be aged 12 or 13, each already seasoned glue sniffers. Some of the women were pregnant, which still didn't stop them getting high, or stop the men hitting them.

The work done with these people on a Saturday seems so feeble and minute when I consider the struggles that they face daily; it's hard enough to keep on living let alone get the strength, determination and opportunity to break out of the cycle. But when community in general has ostracized them then any attempt to reach out in love is a step in the right direction. All we can do is pray for them.


This wasn't really a suitable situation for a camera, and this post is definitely a sobering one. Sorry if it is upsetting or uninteresting; I thought it was worth sharing.. The last few days have been much more light hearted - we spent some time down in Sucre, 12 hours away. I'll write a bit about that and include some photos sometime soon!

Post script

12 hours after thinking that I 'may as well' splash on some spicy locoto sauce liberally on my cow's heart, and that I 'may as well' have a couple extra, I've spent the day in bed feeling sick.
Lesson learnt, although I'll still eat it again if it comes round!

Bolivian food, flora, fire and free health care

One of the interns consulting a local
in the half finished building.

Free health care

Normally Bolivians must pay for everything in the hospital. They pay for the initial consultation, then if the doctor sends them for an x-ray or an ultrasound they pay for that. Then they pay for any medication they need. It's been quite sad to see how much money drives the health care here - often the longest part of a consultation will be discussing the fee. I've seen patients haggling the price down, and other people refusing to go to the hospital since they know it will cost too much.

Every child was given some anti-
parasitic medication before they
were even seen by a doctor!

This weekend we spent a day in a local neighbourhood carrying out a project combining the hospital and the church.  A large group of us went - 1 doctor, 3 interns (who are pretty much unpaid junior doctors), 5 students and the hospital pastor as well as people from his church…

The women in Bolivia all carry
their children in these wraps
on their backs. I tried to take
a photo of the baby actually
in there, but her mum pulled her
out and swung her round!

We were using what seemed to be a sort of town hall; although not really finished on the inside. About 11 to 150 local Bolivians turned up and saw the students to get their height, weight and blood pressure, then saw one of the interns for a consultation of whatever ailed them, then saw the doctor who gave them whatever free medication was suitable for them, and then they were accosted at the exit by the church members who gave them free juice and chatted to them about God. By all accounts it was a pretty successful day; it was by no means ideal care, and certainly not holistic care, but it was definitely better than no care at all.

 Flora

Sunday was the festival of the flowers here. Anocaraire (the area the hospital is in) is apparently famous for producing beautiful flowers, and there were several stalls showing off their best examples. The kantuta flower is the national flower of Bolivia, cleverly designed to replicate the national flag with red, yellow and green.

The Kantuta flower - multiple miniature bolivian flags.

Unfortunately the festival was typical Bolivian entertainment - a man on stage with his microphone turned up to the maximum, shouting in spanish about how great everything is, before introducing a local band who did a very effective job of encouraging us to leave the festival pronto.

Food

The hair-like llama jerky.

We’ve been able to sample several Boliviain delicacies recently. Charque is llama jerky. They tear it up into such small pieces before drying it though that when the plate arrives it just looks like balls of hair, surrounded by the customary maize and potatoes. Why have just one carb when you can have two? Surprisingly tasty though, once you get over the need to pull hair out of your mouth with every forkful.

The locoto and it's spicy sauce.

Another favourite here is anticucho – cow’s heart. This is a real treat. One heart makes about 20 skewers, and easily fed our group of 7 people. The heart is sliced up very thinly, left to soak in vinegar, oil and cinnamon and then pierced with skewers. Once the barbecue is fired up the meat only takes a few minutes to cook. It’s eaten with peanut sauce and a spicy green concoction made from the locoto chili – aptly named since you’d have to be loco (crazy) to eat much of it..

the raw cow's heart

A little bit wary of eating it.

Neco on the grill

Fire

Higher up the hill from the hospital where we live is a national park, with great views over the whole of Cochabamba. Apparently people often go camping up there, which we're keen to do if we get the chance. On Sunday we went up for a few hours in the evening to light up a bonfire and enjoy some marshmallows. It seems that tradition is common worldwide..