Jayson Johnson and Professor Barbara Lockhart, Excercise Science

The main goal of our research was to investigate and gain a better understanding of the perception that local inhabitants of Bolivia have regarding medical aid received in their country. To accomplish this task we surveyed and interviewed those who are most directly affected by this aid, namely medical doctors and patients. As stated in the proposal, our study consisted of two sources of primary data: the first is personal interviews with Bolivian physicians and the second source is the surveys administered to patients and their parents who had received a cleflip and/or clef-palate operation from one of the organizations we were studying.

Initially the two organizations that we set out to work with were Operation Smile and Deseret International. Our preliminary contact with both of these organizations proved to be positive and we designed the study based on the assumption that both of these organizations would maintain their willingness to cooperate in the study. Operation Smile was to represent the short-term medical mission (STMM) model and Deseret International was to represent the empowerment of local medical professionals (ELMP) model. When we finished writing the final proposal and sent it to both of these organizations things did not go as smoothly as we had planned. Deseret International gave us their support and agreed to cooperate with the study. However, Operation Smile decided to withdraw their support. When we asked about their decision and why they had changed their stance, the representative from Operation Smile informed us that the person that had pledged support in the beginning was a regional representative and did not have the power or authority to give the support of the organization. In addition they maintained that the study would be a violation of HIPAA and that “the proposed methods do not assure a completely unbiased evaluation of the two service models”. After this correspondence we offered to work with them and change any part of our study that seemed reasonable but still they refused to cooperate.

Adjusting to this unforeseen complication we contacted another organization named Smile Train and sent them our proposal. They agreed to cooperate and pledged their full support and arranged for us to work with their partner organization Esperanza Boliva. However they only partially represent a STMM model. While they do send foreign medical teams to Bolivia, for their cleflip, cleft-palate patients they pay a local doctor $250 per surgery.

We were able to survey 74 cleft-lip and/or cleft-palate patients. Due to the fact that the majority of the patients were 2 years and younger and all of them were minors, we administered the survey to the parents. We surveyed 16 patients operated on by one doctor representing Deseret International, we surveyed 56 patients operated on by three different doctors representing Smile Train (one of these doctors is employed by the state and does not pocket the money paid by Smile Train but gives it to the hospital), and we surveyed 2 patients operated on by foreign doctors, one from Operation Smile and another from Peru. Before each survey was filled out we assured the parents that the survey was confidential and that we were not affiliated with any of the organizations. The statistical analysis of the surveys showed that the satisfaction rate of all of the patients was very high and there was no statistical difference between the different local doctors performing the surgeries. The mean for all the local doctors individually fell between Strongly Agree and Agree, while all the medians feel on Strongly Agree or Agree. The results from the foreign doctors suggest that there could be a statistical difference but because of lack of subjects we could not run an ANOVA test for the two survey results from the patients operated on by the foreign doctors. A number of patients had traveled across the country from Santa Cruz to La Paz to pay for a surgery. Many of them knew they could receive a free surgery but decided to pay because they had seen children that had been victims of mal-practice so they traveled to be operated on by surgeons who had developed a good reputations for themselves.

We interviewed 16 Bolivian doctors currently practicing in the country, 2 catholic priests, 2 hospital directors (one state hospital and one private), one social worker, and the Department of Health Director in Tarija Bolivia. Among the doctors we interviewed 2 represented Deseret International (an ophthalmologist and a plastic surgeon), 13 represented Smile Train and Esperanza Bolivia (3 anesthesiologists, 4 plastic surgeons, 4 general surgeons, and 2 gynecologists), and one was a plastic surgeon employed by the state and is not affiliated with any non-profit organization.

The general consensus between both the doctors from Smile Train/Esperanza Bolivia and from Deseret International was one of gratitude for the support they had received from these organizations. The most interesting and thought provoking responses came to the question of what the best way of offering this type of aid might be. Most agreed that sending large teams of foreign doctors in to perform a large quantity of surgeries in a short time was not good for various reasons. First and foremost, when these teams come in they do not have to abide by the same set of standards. They are not worried about their reputations; they cannot be sued for malpractice because once they leave, the organizations involved do not take responsibility. Secondly, this practice is fundamentally unsound because they, in effect, steal the experience of performing a particular surgery for themselves instead of allowing a particular case to help a local doctor improve his or her own skills or even help train another surgeon. They raised the concern that while most are qualified to perform the surgeries they set out to perform, some are just looking for more practice with a pathology they don’t see in their own country often enough. Four out of the five plastic surgeons had photo albums full of pictures of children that had been operated on poorly by a foreign doctor. While not all the doctors performing bad surgeries were from the United States, many of them were in fact from the U.S. Despite these complaints most agreed that sending specialists to Bolivia to work directly with the local doctors to help them learn new techniques and how to use new technology was a sound and helpful practice. Those who receive small monetary incentives from Smile Train were grateful for the help and felt it helped them increase their practice and help more children with cleft-lip and palate.

One surgeon felt that although the help he and others receive from these organizations is defiantly a boost for his country, he looks further into the future and feels that the best way to help would be to collaborate more with the surgeons in developing a more sustainable solution, so that when the organization can no longer provide the financial support, the Bolivian medical community can continue to provide its own aid to its people.