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Chamuela (Bolivia)

I started working at the Hospital *********⁵ in 2011. I work as a Medico General. In rural Bolivia, there are no GP practices, so anyone ill or injured has to come and see a medic at the hospital. I treat patients with all illnesses and injuries, from just after birth to more than 90 years of age: anyone who comes to the hospital. The hospital has remained small for the number of people living in and around *********, and it lacks specialist doctors like traumatologists, internal specialists, paediatricians, endocrinologists and gastroenterologists. The Director of the hospital also made me responsible for the Accident and Emergency department (A & E), so I have to write weekly and monthly reports and do 24-hour shifts there at least six times a month while continuing with my other work.

When you work on 24-hour shifts, you see patients with all sorts of problems: patients with tropical diseases and viruses; patients with acute abdomen problems, like appendicitis and cholecystitis; patients with light or severe burns; patients with urinary infections, with hernias; patients with different types of tumours; patients with cancer; patients suffering from polytraumatic injuries. You have to deal with everything from fractures to wounds, from pregnancies and births to self-performed incomplete abortions – you see it all. As a medic, you have to treat all of these patients. The hospital does not have enough, or sometimes any, specialist doctors. Neither does it have advanced technology for diagnosis or treatment, so a lot of the treatment is done by meticulous clinical work with the help of the patient’s own account of their medical history. After assessing the patient, we write a detailed medical history and fill in the many forms needed to solicit the available laboratory work, ultrasounds, X-rays and ECGs, as well as prescription forms and, of course, a diagnosis sheet. In recent months, we have been able to call our available off-duty specialists in the areas of paediatrics, internal medicine, surgery, traumatology and gynaecology to come to the hospital and assess patients if needed. For this we have a communal telephone to contact those specialists. However, as medic on duty you will often have to attend these complicated cases by yourself, if you can stabilise the patient. When we do call specialists on the phone, patients often complain or denounce us to the press or the director of the hospital, saying we only talk on the phone all the time. It is difficult calling specialists at night, because sometimes we do not have credit on the phone. It’s incredible and very alarming. Sadly, the medics in the hospital do the work of doctors, secretaries, statisticians, and sometimes nurses. Its impressive how they deal with all the pressure and stress. In Bolivia, Medicos Generales are truly the worst paid and least privileged and appreciated. They are not valued. Many admirable people do not get the respect they deserve.

There are so many challenges in A & E and often you have to fight tough battles. You have to endure ill-mannered, drunk people that shout at you and insult you. They have no manners and believe the medics are their own special employees. I believe you should not even treat your own personal employees like this. You see fights, physical aggression, sexual aggression … In the hospital, we do not have security guards. Because of this, I had many very stressful shifts between 2011 and today.

Once, a couple came into A & E after attacking each other. The man had a slanting cut near the right eyebrow, the woman a deep round contusion on the forehead after suffering a blow to the head. I dealt with the wounds and put in stitches. This couple had been brought in by the police but the police had just left the couple in A & E and gone. The woman had a sharp blade with a cutting edge to attack her partner. In that moment, my heart was racing, and I felt so desperate when I saw this happening. I felt powerless, and I had to call the police again. When I heard the siren approaching, the aggressor ran away. When there are tough cases like this one – murder, accidents or situations where people lack respect towards us – we do not have the police close by. When we call them, we lose time, and they always arrive too late. Sometimes they also come with patients. There are only a few policemen in the town. When the police come, they often come to ask the medic on duty to register how many patients there are in each ward, rather than to help.

In A & E, I have had so many patients intoxicated with alcohol, illicit substances, and poisons. Sometimes you also get bold patients that make you compliments in their intoxicated state. Sometimes the patients tell you, ‘My darling, how beautiful you are. Doctora, you can touch me wherever you want, doctora.’ One patient that came to see me told me his stomach hurt. I examined him, and he told me it hurt further down and that he would show me where. He lowered his trousers and showed me his erect penis. He covered his face and asked me what I thought. I examined him seriously, but something seemed strange to me, and when I looked more closely, he grabbed me. Another patient lowered his trousers and told me he wanted me to give him an injection, instead of the nurse, and hit himself on his buttocks. Another patient suffering from schizophrenia came to A & E armed with knives, grenades, handcuffs and guns, and only during my shifts, so that I specifically would attend to him. To tell the truth, I had shifts full of terror. When I handed the Director of the hospital a complaint, he only laughed. This is a problem for female medics, not for male doctors. Women do not do these things to them. I had all these bad experiences in my shifts. It makes me so scared of these situations.

Some hospital staff also used to leave the hospital to visit prisoners every Thursday. The prison in the town is a very sad, desolate, and truly disastrous place with bad conditions for the detainees. We discovered this when three staff members went there to give medical attention to the prisoners. There were people who were involved in drug trafficking, murder, robbery and assault. Initially, you do feel a lot of adrenaline when you are inside the prison room, out of fear of the reaction of the people there … But I can confirm that they were friendly and treated us with respect. Once, however, a young man approached us to ask us to treat him for Chagas disease⁶. After we had explained the possible side effects of the drug Benznidazole to him, he agreed to start and finish treatment. Another female colleague and I left the hospital to go to the prison to treat him every five, eight, or sometimes ten days for two months. Whenever possible, I gave him fruit, cereals, cookies and bread, which he shared with his friends. Sadly, when he was going to finish treatment, he started to tell me, ‘Doctor, I am in love with you. I love you, you are my favourite doctor, thank you for doing all the follow-up checks on me. But I am in love with you, I want to kiss you. I want you to be my girlfriend, my love.’ So, when he was released, he came searching for me … This situation I didn’t like. I felt worried and surprised that a patient would say this to me. To be honest, I was very scared. Because a man had asked me to treat him for Chagas, of course I did, and did all the follow-up checks for two months. But this man knew everything about my life. He knew where my family was from, he knew I was single and that I did not have children. He told me to save money for when he came to find me after his release. He said that he was in love with me, and if he had met me earlier, he would not have committed the crime of murdering his wife. This situation made me shudder. After that, I stopped my visits to the prison.

Part of the problem was that there was only one prison guard, the police were on the other side of the block and all the inmates were men. I looked at the situation and realised that the inmates could abuse all three of us female doctors – a psychologist, another Medico General, and me – because there was neither any protection nor any guards close by. I told this to the heads of the hospital. They did not do or say anything. These experiences led to me distancing myself from these people, and it is for that reason that I no longer volunteer to give medical treatment in the prison, because sometimes patients confuse friendliness with flirting. That is unbelievable, but it happens.

Partly because of these kinds of experiences, I fought to have two police officers at the hospital, but I did not have the support of the Director. I even went to talk to the Departmental Director⁷ personally to negotiate the presence of the police officers in the hospital. I believe that all authorities should take this situation seriously and fight to have my plea, which I have already repeated to many people, including the previous mayor, recognised. I asked the mayor to help us put this in practice, but he did not do it. There is a lack of awareness, and we need to make people aware, so they learn to respect health care personnel.

On shift in A & E, you see very difficult cases, for example patients highly decompensated because of diabetes⁸. You see many cases of attempted murder, physical aggression, psychological aggression and sexual aggression. You often see people intoxicated with drugs. This year, many critical patients have visited the hospital. Once, a young girl was thrown from a truck in front of the door of her house and left lying there after having taken drugs with some other people. She had gone to the river with her friends to drink and take an excessive amount of marijuana. She had lost consciousness. Her friends drove her back to her house and threw her on the ground in front of the door like a bag of sand. The people there shouted and called the police, who brought her to A & E. She was completely soaked and caked with sand and suffering from hypothermia. We called for the police, and gave a report, and checked her for signs of sexual violence. It was then that she said she had been subject to sexual violence by an adult since she was eight years old, following which she had attempted to kill herself to forget the situation. She survived, but she did not stop vomiting for a week. I experienced this case on my shift, and it made me so sad that these types of events happen in the village. I have also seen various cases of sexual or psychological violence against young people. These are always difficult situations to deal with. Many young teenagers’ futures are destroyed by unwanted and unplanned pregnancies. They bring babies into the world, sometimes after being raped on the street, or by close family members, but more often because of the lack of information and sexual education. Many young people don’t confide in their parents because of shame. I treated many pregnant young girls between 12 and 19 years old. They tell very sad stories. One, for example, said she did not want her son to see the light of the world because she had been raped.

I have seen how sexual violence psychologically traumatises young girls. What’s more, they do not have the financial resources to raise a child. Because of this, their parents will have to support the child after birth, and help in its upbringing, because many irresponsible men, after satisfying themselves sexually and impregnating the girls, do not assume the responsibility of fatherhood. You also see attempted abortions by young girls. To be honest, you see this in all ages, but especially for unwanted pregnancies in young girls after sexual abuse, sometimes by their own parents, uncles, cousins or other people they know. Abortions are illegal in Bolivia. A study I did, from June 2011 to June 2012, showed 143 pregnant girls between 12 and 19 years old attended the hospital. Of these, the majority were a result of sexual abuse. Sadly, in Bolivia there are cowardly men who do this to young girls and then escape or do not assume their responsibility. They damage the life of those young girls in that way, because their parents force them to work as a punishment in order to maintain the child. But there are also women that abandon the children to evade responsibility, or who give them away.

There is a lack of education and information in schools. In general, you only talk about sexuality in your family. In the past, you could not talk about sexuality with your parents because it was a taboo and a sign of lack of respect, but through technology, young people know much more about many good and bad things. Now, they wake up earlier to sexuality. But out of shame, they do not come to the hospital to receive adequate advice, so they run the risk of getting pregnant and contracting sexually transmitted diseases, including HIV or AIDS. The worst is, once they are pregnant, they cannot go to school or university to study and learn.

The saddest stories I have seen were young girls and boys with terminal cancer. In the town where I work, they don’t do chemotherapy – they only do that in larger towns – because the hospital has neither the equipment needed nor the specialists to do it. On top of that, chemotherapy is very expensive. It’s difficult for the patients that they have to go to a third-level hospital for this, but there is no choice.

I once had to take a 15-hour-old baby boy with sepsis to the nearest city⁹ in an ambulance, in a very bad general condition. He was moaning all the time. He also made crackling sounds, a sign of pulmonary disease. The paediatrician had said he had a high chance of dying on the way. On the difficult road, full of potholes and rough and uneven ground, he started to develop breathing problems. I helped him breathe by giving him oxygen in full flow. When he began turning blue because of the lack of oxygen, I helped him breathe with a bag valve mask (BVM) attached to the oxygen tank. Later I performed CPR. I intubated him and cleared his airways using suction. Despite the CPR, he died in the hospital in the city. Because of this, I cried a lot.

Road tracks are really bad – they are not tarmacked; they are just earth tracks with many deep potholes. These road conditions don’t help when transporting seriously ill or injured patients in need of urgent care. The ambulance does not have adequate equipment to transport those patients. It only has the very basics. It’s sad, but it’s the reality in rural areas.

I also remember doing a Pap smear campaign¹⁰ together with a colleague, and not having the conditions to do the tests, because we only had a few covers for all patients. The bed, a small old wooden school desk, was uncomfortable and unsuitable; the hut was dirty and pitch black due to the absence of electricity. I think all such procedures should be done in a sterile environment, to reduce the risk of infection and for the comfort of the patient. Pap smears manipulate the internal mucosa of the woman’s vagina, and the cervix, and germs can easily be introduced during the procedure, causing infections. The lack of light and microscopes makes it hard to take samples and evaluate them.

It’s incredible that they expect us to work like this, and don’t give us the conditions to do so properly, neither in terms of equipment nor material. Sometimes we had to do Pap tests using flashlights or attend births using flashlights. Sometimes we had to wait because of the absence of electricity, due to the lack of good management. Even worse, in A & E we do not have accommodation or bathrooms. Of course, you have to deal with biological necessities, and you have to walk half a block to find a bathroom. For the love of God, they don’t ever think about the fact that we are humans who can also contract illnesses and become sick.

As an official of a public state institution, you can certainly see that the hardest work is doing the paperwork and writing, writing, writing. It’s very bureaucratic. You lose a lot of time filling out papers, instead of attending patients. The time you waste filling in forms for supplementary exams and medication and the entire clinical history by hand! Working like this for 24 hours for this number of patients is exhausting. Your energy lasts very well for eight hours working without break, but after eight hours you start to feel physical exhaustion and weakening, sometimes dizziness.

Sometimes, very aggressive people come to A & E; they enter shouting and treat us in a degrading way. They are thoughtless because they do not respect the visiting hours of the hospital. They don’t care that a doctor has biological necessities like eating. Sometimes so many people show up that you have to contain yourself not to urinate for five or sometimes six hours. Or they show up just at lunch time. It seems to me that this happens because of the lack of information, or because they do not want to take a ticket for a medical consultation. They don’t understand that doctors are attending emergencies like pregnant patients who arrive at unpredictable times and need our full attention. They threaten to denounce you to the press. Here there is a radio station which works without any ethics. Certain hysterical people denounce doctors for everything and nothing because they do not know that it is neither an emergency nor urgent. So this media source condemns the work of doctors, making unrealistic comparisons between working in health care and working in the press sector – in a hospital, you work with people, to save human lives. Everything is ‘medical negligence’ for people who are neither informed nor know the significance of that word. For example patients suffering from in-growing finger- or toenails for two weeks or sometimes months come to A & E and see that you are treating decompensated patients, patients in hypertensive crisis, patients with heart attacks, snake bites etc., and then shout at you and tell you that if you will not treat them, they will denounce you. They go to the radio to say that the emergency doctors did not want to attend them, that they refused to treat them. The actions of foolish people are incredible.

The mistake made by the press is not to search for and inquire carefully about the correct and truthful information, not false, unscrupulous and corrupt information. In Bolivia there is a law against medical negligence. But there is no law protecting health care workers. I ask myself where the law is against the parents who allow the illness of their children or family members to advance, from a cough to pneumonia, or serious cases of diarrhoea, for a week, and come into A & E when the children are about to die at three a.m. and expect the health care staff to work miracles, and then accuse them of medical negligence, saying that it is their fault the patient died.

I continued to work as the head of A & E until 2015. The position brought with it a lot of responsibility and became very stressful when I was also put in charge of the departmental health and social security programme in August 2014. This is a free social-security programme organised in one departamento of Bolivia for those between 5 and 59 years of age not able to afford health insurance or pay for hospitalisation. It covers hospitalisation and inpatient treatment, both of which are expensive and compromise a family’s savings and livelihood, especially in rural areas, because these families cannot count on economic resources or income. Thanks to this brilliant and very important departmental programme, these people can still receive treatment. I consider it a blessing for the people benefitting from it. The government supports the municipality in this way because of the surplus money made by taxes on the hydrocarbons like gas and petroleum found in the region. My responsibility is to explain to patients without medical insurance how to access the programme. So I ascertain meticulously that the person in question does not have any medical insurance, so that they can benefit from the programme. To do this, every day I have to visit each room, bed by bed, in all the different wards, to see whether patients fall into the age bracket of 5 to 59 years to enrol them in the program. For this, I have to make sure that all of those patients have some documentation identifying them. This is often difficult, as not all patients have such documentation, and many do not remember to bring it when travelling from faraway villages to the hospital. Aside from that, I also have to work with those registered, and see to it that the patient is treated adequately.

From August 2014 until today I brought in more than 200,000 Bolivianos¹¹ to cover the beneficiaries’ medical costs. It gives me so much joy to see this marvellous help for those who need it most. But I am on my own here in the hospital, as there are no social workers, so I have to register all eligible patients, doing the work of a social worker as well as my job as a doctor. It is difficult and delicate to manage the programme, as they named me as the person responsible without training me to do the job. When I first started, I only learnt how to manage the programme through reading the manual detailing the functioning of the programme, having to call my supervisor in the city if I had doubts. Now I know the programme well, so I feel more comfortable with this responsibility, which I really like and feel affection for. Aside from visiting communities to spread information on the programme, I also visit radio stations so that people can hear about the programme and benefit from it. Many times I have clashed with the previous and the current Directors of the hospital, and also colleagues, because they believe that I am not doing anything, when this programme is actually the one bringing most economic resources to the municipality. People are very happy about this programme, because every family benefitting from it saves more than 3,000 and sometimes up to to 5,000 or 10,000 Bolivianos¹². That makes me very happy. Really, the department is very generous in helping seriously sick or injured patients, including people suffering from cancer, where they have covered treatments with chemotherapy.

However, on top of working in A & E for six 24-hour shifts each month, I find it very hard to really deal with the programme, especially since I should also be working on patient transport in the ambulances. But I don’t usually travel with the ambulances, because I suffer from allergies, and have also recently been diagnosed with chronic bronchiectasis. Often, this angers my colleagues; they don’t understand that dealing with a programme of this size is a huge responsibility. They don’t value the fact that they are healthy, and that it is important to take care of yourself and your health very well. The stress has made me ill, as I can neither take days off to rest nor take holidays. I do not understand why it is like this in Bolivia. Here, doctors are not valued or respected at all – we do 24-hour shifts without any sleep. I can confirm from my own experience that stress makes you ill; it’s inhuman and unhealthy.

I remember beautiful moments too, however. One was when we, my colleagues and I, went to the local radio station to share and discuss highly important topics such as domestic violence. In our programme, we analysed some songs, like the song ‘Rata de dos patas’¹³ by Paquita la del Barrio. Like many Reguéton songs, it touched on the topic of alcoholism, something we discussed, and in particular how much damage that can cause to a family. I remember my colleague and friend also brought a song about domestic violence against children once, ‘Luka’ by Suzanne Vega, which had been translated into Spanish. The programme had an effect on violence against children, because the radio station carried out campaigns against violence every time, which was good for the people listening. For the most part, the people committing this type of violence are unemployed or mentally ill people who should have some occupational activity. We covered all these different topics in the programme. The programme turned out to be very interesting for the people living in the communities. When they came to the hospital and heard my voice, they asked me why we did not do more of this programme. They said that they stay up late on Monday, Tuesday and Wednesday, just to listen to the programme from seven to nine p.m. Very beautiful! They also recognised my colleague’s voice. They always told me they were listening to the ‘gringa’s’ voice.

One of the happiest moments for me in A & E was seeing an elderly couple holding hands while waiting to be attended to. The husband was 100 years old, his wife 86. I also felt emotional when I saw a bird coming to visit me one night. He just sat on the emergency treatment box in A & E. But the happiest moments for me are always when my parents, the most amazing people on earth, come to visit me during my 24-hour shifts, when I am exhausted and tired. When I see them and hear their voices, I feel very fortunate and happy.

The most important thing at the moment is to improve the hospital. Partly, it is important to improve the facilities of the hospital; there is a lack of equipment to do examinations with more modern technology. But the principal thing we lack is specialists. I would love it – and it would be a blessing – if in my country there were more possibilities to do specialties in different areas of medicine. It would be wonderful if they offered scholarships and more places. Currently, it is very restricted. For example, in the specialty of dermatology there is only one place for every 100 applicants. I have to say that health and education have improved a lot with the policies of the national government. But I believe that there should be more opportunities for all of us wanting to study medicine. Equally, the health ministry should ensure that all health care professionals always take training courses to stay up to date. In my country, registering for a specialty degree is free of charge, or only costs very little. So this is an incentive for health care professionals. But I think there should be no restrictions regarding specialisation. Many people with economic possibilities don’t have to go out of their way. Their parents cover all the costs of specialising. But in my case I cannot be irresponsible and demand from my parents that they do this for me, because they are senior citizens – my father is 72 years old, my mother 69. I have eight siblings. It is enough that they paid for me to study at university. They gave me a roof over my head, a lot of love, affection, understanding and moral and economic support to move forward. But in the future, I would really like to take up a specialty. I would like to receive a scholarship to do a specialty in dermatology or immunotherapy. I personally suffer from allergies and respiratory problems. For the doctors in Bolivia it has been difficult to treat my conditions. I would like to change that. I also always liked the social aid work I did during my time as a student. So I would love to create a centre to welcome and collaborate with people that do not have any resources, with the help of people with a good heart who want to work in this centre.

However, I sometimes feel like I don’t want to work any more, because the conditions are so hard. In addition, the specialists don’t value general medics; they look down on us, because they feel superior. I believe you should respect and honour the achievements of every person, because everyone is fighting for their goals. I have learnt that we must be grateful for life, for what our parents give us, for the great sacrifice they make for their children. I have learnt that we must be grateful that parents want the best for their children, so that their children have a better future, and children should be grateful for this and work hard to make their parents happy. Likewise, parents should not encourage their children with too much money, because they may go searching for the vices of cigarettes, alcohol and drugs, and not value life. I love my parents. My family is the best thing I have in my life. And I love my friends; they are angels in my life. I am grateful for their friendship and love them a lot.