$Unique_ID{COW00423} $Pretitle{266} $Title{Bolivia Chapter 7B. Health} $Subtitle{} $Author{Thomas E. Weil} $Affiliation{HQ, Department of the Army} $Subject{health percent reported public rural water medical available la paz} $Date{1974} $Log{} Country: Bolivia Book: Bolivia, A Country Study Author: Thomas E. Weil Affiliation: HQ, Department of the Army Date: 1974 Chapter 7B. Health Administration of Health Programs According to a manual prepared in the late 1960s for the training of public health doctors, the coparticipation of various social security funds (cajas-see Glossary) offering medical care for their individual participants has made the public program of medical care one of competition and duplication rather than one of unity and cooperation (see Welfare, this ch.). Generally confirming this judgment, a Ministry of Planning and Coordination publication reported that in 1969 some six of the then-existing thirteen cabinet ministries and fourteen other public institutions had a hand in public health administration. In addition, a small urban elite that probably numbered under 100,000 chose to pay for the good service available in a few private clinics and offered by a few carriage-trade doctors in private practice. The public health training manual noted that, with responsibility for the care of 78 percent of the country's population, the public health ministry had 1966 appropriations sufficient for a per capita expenditure of $b0.59 (for value of the Bolivian peso-see Glossary) monthly (equivalent to US $0.04) as compared with $b18.3 (equivalent to US $1.50) per capita available for persons covered under the individual social security programs. In general, in the early 1970s the medical care program was an urban one. Most of the rural care available was confined to immunization programs and the occasional first-aid and sanitation practices instruction available from mobile health teams. The public health training manual reported that, by political department, availability of service ranged downward from 86.6 percent of the population in Chuquisaca to 19.5 percent in Pando. Health Hazards and Preventive Medicine Only a fraction of the country's deaths are reported, and a substantial portion of those reported are not defined by cause. Acute diseases of the respiratory tract are, however, recognized as the principal causes of death. According to one official report, in 1967 respiratory ailments were followed in order of incidence as causes of mortality by diseases of early infancy; senility and poorly defined causes; diseases of the digestive and intestinal tract; tuberculosis in all forms; rheumatic fever; accidents and violence; arteriosclerosis; and cancer. There was some regional variation in the causes of death. In all of the country's nine departments acute respiratory ailments ranked either first or second in incidence. In La Paz, Chuquisaca, and Oruro accidents and violence constituted the other principal cause. Digestive and intestinal tract ailments were most important in Sucre, Tarija, Cochabamba, and Pando. Intestinal parasites were listed in El Beni and bacterial infections in Santa Cruz. It has been officially estimated that diseases causing 10 percent of mortality (such as yellow fever, smallpox, rabies, and typhus) can be completely eradicated and that those causing 80 percent (such as tuberculosis, diphtheria, tetanus, and polio) can be substantially reduced in incidence. The campaign against these ailments would involve combating traditional health attitudes, improving nutritional and sanitation levels, and better utilizing the already available resources for health improvement. In particular, unsanitary and crowded housing combine with poor ventilation to result in a dangerously ready interchange of communicable diseases, particularly during sleeping hours. Mortality is by a wide margin highest among the very young. One-fourth or more of all infants die during the first year of life, and almost half of all deaths reported in 1968 involved children under the age of five years. The number of deaths under the age of five was almost ten times that between the ages of five and fourteen. In the more remote parts of the countryside, delivery is presided over by an unschooled midwife or family member who severs the umbilical cord with a broken piece of pottery-in the belief that use of a metallic instrument may cause the child to develop a belligerent character. No attempt is made at sterilization, and the baby is made particularly susceptible to respiratory ailments by the frequent practice of wrapping it in swaddling clothes in the belief that the child will thus be endowed with a strong, straight body. Parts of the anatomy are released from the swaddling for increasing lengths of time, but the child may be two years of age or older before swaddling is altogether discontinued. Because breast feeding is believed to be conducive to strong muscles and virility, boys are frequently not weaned until they are old enough to attend school. An immediate goal proposed by public health authorities during the late 1960s involved medical or paramedical care for at least half of the rural deliveries. It would include three or four consultations during pregnancy, and most deliveries would be handled at a health post by a trained midwife or a nursing auxiliary; difficult deliveries would be handled by a doctor at the nearest rural hospital. These modest objectives appeared still far from attainment. A 1968 survey of eighteen rural communities in Cochabamba (a department with better than average availability of medical care) found that 8 percent of all births were attended by doctors and 21 percent by midwives who probably had little if any training. Some 15 percent were attended by traditional practitioners (curanderos), and the remaining 56 percent were attended by family members or neighbors. Some 92 percent of the deliveries were in the home. Mining is the employment sector with the most serious health hazards. Estimates of the proportion of miners afflicted with silicosis range as high as 40 percent. A smaller proportion contract silicotuberculosis, and the average age for retirement with disability pension was reported to be forty-one years during the late 1960s. In addition, intense heat in the mine shafts followed by exposure to the outside chill of the high altitudes made mineworkers particularly susceptible to respiratory diseases. There has been an increase in the reported countrywide incidence of tuberculosis since the end of the Chaco War (1932-35), a trend which may at least in part be the result of a greater frequency of migration of campesinos to the tropical lowlands, where they are believed to be more susceptible to the disease. The apparently greater incidence may, however, be a reflection only of improved medical reporting. In any case, the combination of crowded and unsanitary housing and low nutrition levels makes much of the population highly susceptible to the several forms of tuberculosis that the World Health Organization in its 1962 annual report declared to be Bolivia's principal health problem. The government estimated that there were 55,000 active cases in the country in 1961, and new cases reported rose from 1,471 in 1964 to 2,947 in 1969. The two mosquito-borne scourges of the lowlands, malaria and jungle yellow fever, seem to have been brought under a degree of control by recent eradication campaigns. In 1970 the examination of 167,265 slides resulted in detection of only 6,862 positive malaria cases. The number of reported cases of yellow fever declined from thirty in 1960 to two in 1970, and eradication of the aedes egypti mosquito, which acts as the vector, had been declared complete in all areas of the country believed initially to have been infested. Until recent years Bolivia had the highest reported incidence of smallpox in the hemisphere. A mass vaccination campaign, begun in 1958, continued intermittently, and no cases were reported during the years 1966 through 1970. As a precautionary measure, however, more than 300,000 vaccinations were administered during 1970. Leprosy is increasing in reported incidence, particularly in the Oriente. In mid-1969 there were 1,560 active cases, all under surveillance, in the recovery center at Los Negros in Santa Cruz Department and in the Monteagudo program in Chuquisaca Department. The Monteagudo program has received assistance from the German Mission for Aid to Leprosy Patients. Plague has been a constant concern of health authorities. Between 1960 and 1970 there were 460 cases reported, the fourth largest number in the Americas, and some were reported every year except 1962. All forty-one cases in 1970 occurred in La Paz Department, where there had been a violent outbreak in 1969. In 1956 yaws was discovered in the provinces of Nor Yungas and Sur Yungas in La Paz Department, and studies revealed that 5,000 persons in a population of approximately 50,000 had contracted the disease. An eradication campaign reduced the incidence by 50 percent in a little more than a year, however, and no new cases were reported in the late 1960s and 1970. Medical Personnel The 1,702 physicians reported in practice in 1968 by the Pan American Health Organization represented 3.6 per 10,000 of the population. Although the proportion was little more than half the average reported for South America, the number reported in practice may have been too high. At about the same time, an Organization of American States (OAS) publication estimated that there were probably not more than 1,200. Physicians and surgeons are trained in seven-year courses at the universities in La Paz, Cochabamba, and Sucre (see ch. 6). Medicine is a profession commanding the highest order of prestige, and the medical schools never suffer from a shortage of applicants. The average of 140 graduated annually during the late 1960s, however, exceeded the country's effective demand for doctors. The problems of the Bolivian doctor are legion. As an intern he may be required by law to serve for two years in a rural hospital. If called into rural service he finds himself in a kind of halfway state between modern and traditional medical practitioner; sometimes his appointments with patients are made by peasant syndicate secretaries who make the determination as to whether the illness involved can best be served by a twentieth-century doctor or by a witch doctor. The story is told of one physician in rural practice who was unable to attract patients until he gained the trust of the community by ministering effectively to a sick donkey. Returned to the city, the doctor is unable to find work. Bolivia has so chronic an oversupply in relation to the effective demand that the training manual for public health physicians described young doctors as "the army of the professional unemployed." In the late 1960s the number of unemployed registered physicians was estimated at 18 percent of the total, and there was a heavy flow of emigration in the medical profession (see ch. 6). According to one report, there were some fifty Bolivian doctors in the city of Chicago alone. In 1969 the number of dentists in practice was listed at 627, or about 1.3 per 100,000 of the population. The limited data available indicate that a majority of the dentists, unlike the physicians, engaged in private practice. Dental work consists primarily of extractions, and in rural localities visiting doctors and paramedical personnel are frequently pressed into service for tooth pulling. In 1969 there were reported to be 612 graduate nurses and 1,549 nursing auxiliaries in the country. These numbers represented 1.3 and 3.2 respectively per 100,000 of the population. Graduate, but not auxiliary, personnel tend to be clustered in private practice. Graduate nurses receive a thorough professional education. Until 1962 some three years of university level training was required; during that year the course was extended to four years, and various fields of specialization were added. Recognition of the nurse as a trained professional has yet to be fully accepted in Bolivia, however. Even trained medical personnel tend to think of anyone capable of administering first aid or an injection as being a nurse. Salaries are low, and during the late 1960s it was estimated by the public health ministry that 50 percent of the country's graduate nurses had gone abroad. Medical Facilities In 1968 the country's 318 hospitals maintained a total of 10,734 beds. Hospitals with fewer than fifty beds constituted 38.7 percent of the total, those with fifty to ninety-nine constituted 15.3 percent, and those with 100 to 499 constituted 40.6 percent. The 532-bed Miraflores General Hospital in La Paz was the only unit with more than 500 beds. Nearly 90 percent were general hospitals; most of the remainder were equally divided between hospitals for mental illnesses and tuberculosis sanitariums. Hospital units were about equally divided between those supported by the public health program and those supported by the several social security entities. Among the few privately operated institutions was the Clinica Americana operated in La Paz by the Methodist church. Early in 1973 the government announced that it had begun negotiations with the Inter-American Development Bank (IDB) for a credit with which to finance the new 500-bed public health Hospital de Clinicas in La Paz, construction to begin in 1974. The number of beds in relation to the size of the population as a whole, reported at one per 522 of the population in 1968, was among the lowest in Latin America. The occupancy rate of less than 60 percent of the beds, however, was also among the lowest. Nearly all the units were located in urban places, but the incomplete data available indicate that the bed occupancy rate was higher in the big urban institutions than in the small rural hospitals. In the relatively few places where rural hospitals were available, in the early 1970s people had not yet become fully aware of their utility: the cornerstone of the first rural unit had not been laid until 1960. In the mid-1960s the military hospital in Riberalta was the largest in El Beni Department, and the ten-bed military unit in Cobija provided the only service in Pando Department. For some of the more remote places where no regular hospitalization facilities exist, the government maintains a small flotilla of hospital vessels. In early 1972 it was announced that two additional vessels would be added to those already in operation in the Oriente region on the Beni and Madre de Dios rivers. In addition, a naval hospital craft was reported to be following a regularly scheduled itinerary of sixteen ports on Lake Titicaca. Traditional Medical Practices Minor respiratory ailments, headaches, and toothaches are believed to result from minor causes and are treated largely by herbal remedies. Coca leaves are commonly used as poultices for the relief of pain, and a variety of herbal teas are used in cases of digestive upset. An infusion concocted from specified quantities of four different herbs serves to regulate menstruation. Together with the herbal remedies, many of which have considerable pharmacological value, incantations and magic charms are used in treatment of real and fancied ailments. In the treatment of goiter and lymphatic swellings, for example, a mouse is sometimes applied as a poultice, and llama fetuses are sold as protection against witchcraft. Severe diseases are seen as the direct result of supernatural causes. Both Quechua and Aymara speakers believe in the possible detachment or disappearance of the soul, a condition that can cause death if the condition is not treated promptly. In particular, the loss of the soul can occur as a consequence of sudden fright (susto), a cause to which many infant deaths are attributed. The treatment of supernaturally caused ills almost invariably involves divination in an attempt to discover the human agent, if there is one. Where there is evidence that a malevolent person has worked black magic on the victim, a common practice is to bathe the victim and to splash the bathwater over the doorstep of the malefactor. Another common practice, used whenever the curer believes the disease to have been supernaturally caused, is to place objects of the patient's clothing in a conspicuous spot on the road in the hope than an unsuspecting stranger will pick them up and thereby contract the disease, freeing the ill person of the curse. In times of epidemic a similar practice is sometimes followed: a black llama is loaded with personal effects of the diseased victims and driven from the village. There are various kinds of specialists in the traditional diagnosis and treatment of disease. A majority make use of both practical and magical treatment. In most communities there are practicing midwives, and in most there are men who specialize in the setting of bones. The best known of the folk practitioners are the Callahuayas of Munecas Province in La Paz Department, who travel the length of the country selling herbal remedies, charms, and amulets. The arrival of one of these itinerants is a village event of great importance. Traditional medical practices are not entirely confined to the countryside. A substantial section of the street market in central La Paz is occupied by vendors of folk remedies and charms. Attitudes of the rural people toward modern medicine reflect a considerable eclecticism. Those for whom medical facilities are readily available will often use modern and traditional cures-and curers-on an alternative basis. In some areas there has been resistance to practices such as vaccination, but the opposition mounted has seldom been strong. In the Altiplano towns, and occasionally in the cities as well, the pharmacy may represent a hazard as well as a cure. Most drugs are available without prescription, and the druggist may also be a traditional practitioner. In the La Paz press a regularly carried advertisement concerns a product guaranteed to restore male virility. In the towns, sophisticated but little-tested European drugs are available, and the prescribed doses are given in languages certainly meaningless to the druggist as well as to the purchaser who, as often as not, is illiterate. The druggist has often received some training, however, and the products sold are frequently of value. Hazardous as they sometimes are, the village-store products probably save many more lives than they destroy. Sanitation In the early 1970s the water and sewerage systems were seriously deficient. Virtually all of the rural and most of the urban populations had direct access to neither, and the OAS had estimated that 15 percent of the country's disease could be attributed to unsafe water. According to official data, in 1969 about 34 percent of the urban population was served by water systems, and about 21 percent had sewerage outlets. In rural areas, service in both was virtually nil. In Bolivia, as in most Latin American countries, water service is customarily described as service with agua potable (potable, or drinkable, water). It is often something quite different; it can better be defined as water of any quality delivered through a system of conduits. Of those households served with agua potable it is probable that in the early 1970s about half had interior connections and the remainder were within a short walking distance ("easy access") of a public fountain or tap. Water, sewerage, and refuse collection are conveniences available only in the larger urban communities. Only a small proportion of the farm population has provided itself with latrines, and few public facilities are available in cities and towns. The public environmental sanitation program is under the general direction of the National Potable Water and Sewerage Corporation (Corporacion Nacional de Agua Potable y Alcantrillado-CORPAGUAS), created in 1967 to determine the general policy of water and sewerage supply on a national scale and to provide systems in localities unable to provide them. The general public policy-reaffirmed by President Banzer early in 1973-is for local governments, where possible, to install these services. A summary of expenditures on water and sewerage during the late 1960s showed that about half the funds came from domestic sources and about half from foreign credits. Details showed that participating agencies had included the CORPAGUAS (water supply for thirty-five small towns), Ministry of Defense (rural water supply), Ministry of Social Service and Health (water for rural schools), and several municipal and departmental water and sewerage entities. The urban water supply problem is at its most acute in La Paz, a direct consequence of the city's rapid growth. The piping was installed in 1923, and by the early 1970s it had been mended and extended many times. Mains had eroded, cracked, and rusted-and sewer lines laid in the same trenches sometimes resulted in contamination of the water supply. The best sewerage is provided in Santa Cruz, where a model system was installed in 1970 with IDB assistance. There are no sewerage mains other than those in La Paz and the departmental capitals, and the manual for public health doctors noted that in the late 1960s no more than 4 percent of the rural population had any installations for the disposal of human wastes. Refuse collection in the larger urban localities is generally satisfactory, although it is in some part accomplished by private contractors. In towns and villages much of the refuse is simply thrown into the street, where it is devoured by dogs and pigs. In general, economic imperatives are such that very little trash and garbage are generated. Empty tins, bottles, and cartons find ready use, and animal excrement is used for fuel or fertilizer.