The Cabildo in El Alto

Everything is closed today. The city is even more deserted than it was on the 16th of July, La Paz Independence Day, because today is the Cabildo, the meeting held in El Alto to protest the possibly movement of the seat of the government (administrative capital) from La Paz to Sucre. The hospital was eerily quiet - the Claudias and a few nurses were the only people I could find – and there were no mini-buses sputtering up and down the streets. Because it seemed like the whole city was in El Alto, Alison (my roommate) and I decided to head up to the Cabildo to check out the scene. The speeches were scheduled to start at 1:00, but because people from all over the Department of La Paz (which includes La Paz, El Alto, Lake Titicaca, and the neighboring mountains) had come to the meeting, the streets in and around El Alto were completely packed as early as 11:00, making it very hard to get near the action.

We found a trustworthy taxi to take us up the “back way,” which instead of the highway-like Autopista is a set of narrow and mostly cobblestone streets that wind through the heights of Sopocachi Alto. It’s actually the same route that the taxi used to take me from the El Alto airport to the city center when I first arrived, and the trip was just as stunning in the daylight. The taxi took us as close as he could get to the center of the Ceja, the center area of the Cabildo, and we (surprisingly) only had to walk about 5 blocks until we were fully immersed in the horde of people gathered around the platform and cheering on the speakers.

It was a fascinating experience being in the middle of not only a political, but also a cultural rally. Situating the administrative capital in La Paz, with its location in the Andes and with it’s heavily Aymara population, is symbolic of the political and cultural importance of the indigenous people. After the election of Evo Morales, who is the country’s first Aymara president, for the first time in the history of Bolivia the indigenous people (who only received voting and land-owning rights in the 1950s) seem to have representation and recognition in the government. Also, the decision to hold the Cabildo in El Alto is meaningful because La Paz’s sister city is considered the indigenous capital of Bolivia, further emphasizing the importance of the indigenous community. If the administrative capital were moved to Sucre, which is in the south of the country, I think many people in La Paz and El Alto feel that the newfound appreciation of indigenous rights and culture would disappear.









[People cheering as a helicopter, possibly with Evo Morales in it, flew by]

[“In Defense of the Department of La Paz: The Seat of the Government Will Not Be Moved”]




[Flag of the Aymara Nation]



[“The Rich Also Cry: They Can’t Govern Us Anymore”]





Being one of only two white people walking through the streets of a completely indigenous community, I sensed an interesting mixture of curiosity and also hostility. People all around me were looking at me with such scrutiny that it was impossible not to feel subconscious. Some people would shyly smile, while others would snidely call us “gringas” under their breath. When one woman saw me with my camera, she grabbed my arm and started to yell at me in Aymara (I think that some indigenous people believe that cameras and photography can steal their soul). When we were sandwiched in the middle of the crowd, most of the people were paying more attention to us, trying to figure out what we were doing holding Bolivian flags in the middle of the Cabildo, than they were to the political speakers.

I know that these people have an incredibly history of oppression, but it really bothers me that foreigners are consistently treated with such hostility. I guess I just don't understand how there can be such malice when we are clearly there to appreciate the politics and indigenous presence of the country.

The Cost of Medical Care

I found out today that my interns, the Claudias, are moving to another unit tomorrow after a 20 day stay in the Unidad de Infectoligia. At first I was quite worried, thinking "How am I going to deal with this, the reason I enjoy work right now is because I like the two girls so much, oy oy oy..." But I've adopted a "this is the way things work" attitude in my time here, since the decision about whether I follow the chicas to their next assignment or stay in my current unit is out of my hands. It's just that it's hard to have to build a relationship with two new interns, especially after I was just getting close to these two. Oh well.

Today I was asking Claudia #1 a little bit about how the healthcare system works. As I've been stressing over and over again, the Hospital de Clinicas treats the poorer people in the system, and it functions as a sort of social welfare system. This is reflected both in the cost and quality of treatment. Apparently, if patients do not have "seguro" (insurance) it costs them *ba dum ching* 20Bs per day to be interned in the ward. For those not familiar with the conversion, that's about $2.5 a day. I know that the cost required of patients does not amount to the cost spent on a patient, but I was doing a bit of research, and the cost per patient per day in U.S. hospital is more than $1000 a day, on average, and for patients with bedsores it is more than $2000. I can't find the cost per patient per day for the Bolivia hospitals, but I can guess that it's around $50 a day. (This website indicates the cost per patient per day in countries such as Tanzania, Kenya, and India is less than $20 a day.)

Also, today when I stopped in for a brief chat with Dr. Revollo, he said his usual "Ohhhh Nadine, deliciosa!" and then followed it immediately with "Did you eat some seafood with garlic last night? I can smell it!" I had to stop and think for a minute, and then remembered that I'd made and eaten roasted garlic. Embarrassed, I told him "Yes, but I brushed my teeth?" He just smiled and said "It's in the blood."

The Socioeconomics of Healthcare

Now that I've been working long enough at both the Hospital de Clinicas and the Hospital Militar to get over the initial shock value and start to observe interesting things about the patients, I've begun to realize quite how different the two institutions are. Both are governmental institutions (not private), but there are a few key differences. The Hospital de Clinicas treats the poorest patients in La Paz and El Alto, and it seems that most patients (understandably) use it as a last resort for medical treatment...which also means that most of the illnesses are quite grave by the time they are treated. The Hospital Militar, in contrast, is open to members of the military and their extended families.

Most strikingly is how differently the patients dress in each institution. In the Hospital de Clinicas the people dress in the “indigenous style” (forgive my crudeness, I don’t know how else to describe it) – the women wear the clothing typical of cholitas, and the men wear simple pants and sweaters. There is no makeup, and things are often worn, stained, or torn. In addition, people bring their snacks or chores (the sister of one patient brings her knitting every day) to the waiting room. In the Hospital Militar, the women wear paint suits and makeup, and they dye their hair, while the men wear nice suits or military uniforms and have shiny leather shoes. Interestingly, the Spanish is also a lot easier to understand in the Hospital Militar, probably because it has less of an Aymaran accent.

It’s kind of interesting to think about how in one place I’m seeing a woman with peritoneal (abdominal) tuberculosis, while in the other I’m seeing a little boy who has a wart on his hand. I’m sure there are areas of the Hospital Militar with more serious infections, but compared to the Hospital de Clinicas it feels like a walk in the park. For example, today a mother brought in her 6 year old boy who had some sort of viral warts or pox in the interior of his bottom, and for treatment (they’re contagious I think) they had to be removed one-by-one with a pair of tweezers. This involved having the boy lay down on his stomach with his pants pulled down as the nurse attempted to anesthetize his bottom. His mother was telling him that it wouldn’t hurt at all, but as soon as he felt that needle, he started crying, screaming, and clenching the muscles in his bottom. “Tengo miedo de las agudas, quiero ir a casa AHORA!” (I’m afraid of needles, I want to go home NOW!) I felt genuinely sorry for him, because until recently I’ve had a mortal fear of needles (along with fire), and I always hated when doctors would tell me that the needle wouldn’t hurt when it was always extremely unpleasant. But at the same time, the situation was inherently funny – here were the nurses wrestling with this little boy’s clenched but muscles while his mother told him to stop crying. I didn’t know whether to cry from sympathy or burst out laughing.

I find it hard to take an episode like that seriously after treating infected bedsores.

Jail Cell for Rent

Treating that patient from the La Paz jail the other day made me realize that I haven't had the chance to talk about how fascinating the jail system is here. The main jail is called San Pedro, and the BBC did an excellent photojournalism piece on the place not too long ago. Unfortunately my knowledge is pretty limited because it isn’t easily accessibly to foreigners (there are no tours) and because, thankfully, I don’t know anyone who has lived in the jail.



[The Plaza outside of the Jail]

[Family members lined up outside of the main entrance]

[San Pedro Church]

Before I lived in Sopocachi I used to walk by the jail almost every day without realizing it because the area is so well integrated into the rest of La Paz. The building is pretty unremarkable other than the fact that it has no windows, but more striking is the complete absence of extra security precautions. There are no barbed wire fences or control towers, and the only policemen are those stationed right at the front door. Interestingly, most of the street vendors seem to cater to the “jail crowd” and sell significantly more hard alcohol and drinks, as opposed to fresh fruits and vegetables.

The way I understand it (and I’m sure the BBC article explains it much better), is that people go into the jail and are expected to not only pay for their living space, but also all of their provisions. The cells range in cost and quality, and prisoners sometimes resort to bringing their families (especially children) to live with them inside the prison. I don't think there's a security system, so people have to work within the jail to pay for their cell space. I don't understand how prisoners are prevented from escaping to roam the streets.

So just like everything else in Bolivia, the government doesn’t seem to have the resources (or the desire) to provide supplies/services for incarceration. It’s interesting when you think about how much money the United States spends on both medical care for the underprivileged, and on keeping large portions of the urban poor in jails. In addition to wondering how anyone can possibly recover in the Hospital de Clinicas, I’ve been surprised by how much these doctors can do for patients with so little supplies (and for such little cost). I’ve also begun to wonder if there’s some balance point between spending very little on patients and keeping them in the hospital for a long time because they don’t recover, and spending more money and speeding up recovery time. It would be an interesting study…if only La Paz had any sort of data collection system for these things.

Copa America and Curaciones

Yesterday, as I mentioned before, was both the Independence Day of La Paz and the finals for the Copa America - the soccer tournament that is basically the Latin American World Cup. Soccer is a huge deal in Latin America, kind of like Football is in the US, so you can only imagine how excited people get about this tournament. The whole point of soccer (for me at least) is that you go watch it with a bunch of fans and be there for the collective experience, so I headed out to the nearby coffee shop. The finals were Brasil vs. Argentina, and while Argentina was favored to win, I decided to cheer for Brasil because I feel that they’ve represented the spirit of Latin American soccer for a very long time. The whole place was filled with Argentinians, chain smoking their cigarettes and looking arrogant, but I found myself in a corner with a tiny group of very loud, very energetic Brasilians. Brasil finished with a pretty definitive 3-0 win, so while our crowd was making merry and being obnoxious in the corner, the rest of the coffee shop was giving us dirty looks and taking long, annoyed drags from their cigarettes.

Today, despite it being a very important holiday, I decided that I would go into work at the Hospital to see if I could be of any help. On my way over this morning this city was markedly deserted. None of the usual shops are open, and the traffic has been reduced to about half. When I got to the hospital it too was deserted – only a handful of doctors were there, and there were no patients or students wandering around the corridors. Due to the low volume of hospital traffic, the two Claudias actually had time to do their “curaciones” (treatments) early in the day, so for the first time I was able to watch the actual process involved in treating and dressing wounds.

I almost ended up going home because we couldn’t find an extra face mask and hair net (I was not about to deal with sick patients without them), but I ended up borrowing one from Claudia #2, complete with makeup stains (they re-use them here). The majority of the cases currently in the ward are infected bedsores, which while interesting from a medical and immunological point of view, are quite disturbing. The first patient we treated, a 60 year old woman with both a mental and physical disability, was quite the introduction. The patients in the nearby beds had to leave the room because of the apparent smell (I was breathing through my mouth) of this woman’s two bedsores on her back and hips, the smaller of the two (about 3” in diameter and exposing her hip bone) which was infected and oozing a nice grayish liquid. Although I don’t like the sight of blood, I would say that I have a pretty strong stomach for these things after several years of working with animals in my lab…but I was this close to running to the bathroom to vomit after the sight of her wounds. The only way I could stand being there was by forgetting that this woman was a living, breathing human being, which presents quite a quandary for me after my critique of how the doctors here treat these people more or less like animals. But now that I actually have experience with treating patients, I can say that this is the only way I can handle medicine, by putting up some sort of mental block.

The actually procedure of treating these patients involves wiping down the wounds with an antibiotic, the hydrogen peroxide, and then iodine (no anesthetics are used to ameliorate the pain). While the tools in the US come individually wrapped in plastic and are discarded after a single use, these tools come in burlap sacks in a sort of “kit”, along with the cotton, the gauze, and the tray for pouring the treatment liquids (I just hope it’s all been sterilized). I’m not so familiar with the procedure for treating bed sores in the US, but I can tell you that when the interns used a minimal amount of clear packing tape to secure the gauze, my head started to explode. I couldn’t stop thinking, How does anyone leave this place alive?

All in all I got to help out with 6 patients, most of them with bedsores. One man is actually a prisoner from the city jail (a car thief, so I’ve heard), and he’s there because he was (apparently) playing soccer, received a small injury on his leg, and then winded up with an infection that ate away at all of the skin from his ankle to his upper thigh and left the muscle exposed. So while one leg is wrapped entirely in gauze, the other is tied to the bed with a chain…as if he’s going anywhere, anyway. I also had the delightful experience of treating the 15 year old boy with cerebral palsy, which isn’t so bad because of his wounds, but because of the piercing screams he lets out every time we try to move him. This poor child is so pathetically thin and incontinent, and he moves like a lizard, waving his cross-eyed head back and forth as he reaches his arms out to grip his legs or my hand.

Now that I’ve been there for a few days, and now that I’ve proven that I’m there to get my hands dirty, a few of the nurses and patients have started to warm up to me. They’ve stopped going “oh my, there’s a gringa” and started to ask me questions like “Why exactly are you here?” I had a bit of a shock when the attending nurse asked me “So, what do you think of that guy who’s in the government in the US?” As I started talking about how I despise President Bush (she couldn’t remember his name) and how I think the War in Iraq is a disaster, just to make sure she was following along I asked her if she knew about the War, and he reply was “A little bit, I’ve heard of it.” That was when I realized that an awareness of International News is basically non-existent here. It’s a different world, in every respect.

Hike to the Cemetary

I’ve been feeling a bit restless for the past few days, so I decided that I would take a hike today from my apartment in Sopocachi, which sits at the far south-east end of the city, to the Cemeterio of La Paz, which is at the opposite north-end of the Prado. On my way there I passed through the food section of the upper markets, which was even more crowded than usual because today is the 15th of Julio, the day before the “Independence Day” of La Paz.















There were also quite a few fiestas in the street, and one group was especially endearing – I heard drums and trumpets blasting from about two blocks away, and when I wandered towards the music saw a group of people dancing, singing, and laughing as taxis and buses rolled by.









After huffing my way up quite a few steep streets, I finally found the cemetery (I could literally feel the change in altitude). Amidst the bustling markets and street vendors, not to mention the smell of fried and roasted meat that is even quite enticing for a vegetarian, the cemetery was a large and fenced-in, and was surprisingly filled with trees and greenery. In comparison to the cement, cobblestones, and trash in the streets, it’s quite shocking to see a little oasis in the middle of a rather poor area.

The La Paz cemetery differs from those in the United States in several ways, but most markedly by the fact that people are not buried underground, but instead stacked vertically in building-like structures, as many as 10 “people” high. Instead of stone gravestones, each person has a little glass enclosure where their family members place fresh flowers, mementos, etc. There was so much greenery and fresh flowers that I didn’t feel like I was walking through a cemetery – instead of the somber, creepiness of American cemeteries, it had a festive and peaceful ambience that was almost akin to a sculpture garden.





[Flower market across the street from the cemetery]

Valle de La Luna

Today I decided to venture out of the city to see some famous rock formations called the Valle de La Luna and its accompanying town Mallasa. The Lonely Planet guidebook gives a brief description on how to get there, either by hired taxi for 50+Bs or a minibus for 2.50Bs, which I opted for. After about a 20 minute wait I found a minibus going that far into the county, and it was actually quite a comfortable 30-minute ride. We first drove through Obrajes and Calocota, the two components of the Zona Sur which I had explored briefly in the past, and then crossed the Rio Choqueyapu, the foaming orange river that runs underneath La Paz and dumps out further into the valley. The filthy river is used as an open sewer, and while it’s kept underground in the more populous highlands, in the lowlands it is used, despite its contents of sewage and chemicals, for the irrigation of the crops that make their way back to the city – thus my avoidance of unpeeled fresh fruits and veggies. Once we had crossed the river, the road turned into a rough cobblestoned path that wove through the smaller, further out villages. While the poverty and aridness of the terrain no longer shocks me, it was very strange to see crude brick, windowless houses within twenty feet of huge, elaborate fenced-in mansions. The juxtaposition of the poverty and the wealth is so blatant and shocking.

Although I was a bit confused about when to get off the minibus, I managed to find the place because (contrary to typical Bolivian fashion) it did have a relatively large sign marking it as a tourist destination. The Valle de La Luna was every bit as surreal and wonderful as the guide-book suggested – it was a large, fenced-in area with a narrow trail winding through the rugged, sandy rock formations. The terrain is actually quite desert-like, and it’s considerably warmer because of the pounding sunlight and the lower altitude. There was even a bit of grass speckled in with the numerous cacti jutting out of the sides of cliffs and the occasional flowering bush. The view from some of the higher points was breathtaking, and afforded a view of the mountains, the valley, and even bits of the Zona Sur.



































[A view of the roads near the entrance]

To complete the serenity of the Valle de La Luna, two men were standing on top of the rocks playing wooden flutes and chirangos (traditional Andean instruments that look like mini-guitars). The sound projected all the way across the hiking area, and it made the experience simply perfect. I complemented the guy on his music afterwards, and although he tried to sell me a flute, he did show me how it worked and how he could play 3 octaves with only 8 stops/holes.

[Chirango player perched on the rocks]



The whole trail took about an hour and half because I was taking so many goddamn pictures, and afterwards I decided to trek down to the accompanying village, Mallasa, to find something to eat. I skipped the Zoo because I’ve heard that the animals are quite depressing, and instead found a hole-in-the-wall joint selling nothing more than ice-cream and cheese empanadas – my first experience with these delicious pastries of La Paz.


[The town of Mallasa]