Cameron Nelson

With the breathtaking view of the Andes through my bus window last Friday morning, I thought of the many Bolivian mothers who would bring their sick children into the Senkata Clinic that day. The June temperatures dropped significantly at night, and I wondered how many children would awake that morning with a severe cough and difficulty breathing, signs of pneumonia. Over the past seven weeks, dozens of children affected with acute respiratory infections (ARI) stared at me with huge brown eyes, reflecting extreme poverty, malnutrition, and fear. Their mothers often called me “Doctor” and looked at me as I interviewed them with amazing trust that I would be able to help their “wawas” get better.

ARI is the third leading cause of death among children less than five years old globally accounting for 21% of all deaths. (I’ve heard that it is the number one killer in children under five in Bolivia). Although it can easily be treated, there are several factors that prevent adequate treatment and child survival. The main steps of child survival include: 1) caregiver recognition of warning signs and symptoms of ARI, 2) treatment decision making, 3) access to treatment, 4) the quality of treatment. This is called the “pathway to survival”. The main purpose of our research was to find out where exactly the breakdown is in the pathway to survival. Is it that the parents don’t recognize the symptoms? Or is it that they don’t know where to take their kids for medical care? Or is there not enough access to adequate treatment? Or is the quality of the treatment in the clinics the problem? Those are the main questions we are trying to answer with this study.

I learned early on that it takes time to make sure everything in a study is precise and correct. We adjusted the study a bunch since those that visit the local communities to find out who is sick with ARI (“los promotores”) no longer exist. It was too hard for them to find the parents home with their kids since they work literally from 6am to 10pm every single day just to make ends meat. Since much of our study was based on the help of these “promotores” we were forced to make some serious adjustments. We tried meeting with “las mazaneras” that make visits in the communities as well to see if we could get the data necessary to find out how many children affected with ARI never make it to the clinics. We still have not received any worthwhile data from them. Currently we are still trying to figure out how to find the children in the communities who never make it to the clinics. We have discussed different options like asking everyone in a certain community who they know is affected with ARI symptoms, in addition to attending community meetings and asking others the same there. Finding those children who never make it to the clinic with ARI is an imperative part of our study. Otherwise, our data will be lopsided and biased with only the children that make it to clinics.

My job for the past seven weeks has been to bite through all the start up cost of initiating a study that is going to make a difference in the lives of many children who suffer from ARI. This meant eliminating as much bias as possible, by working with many NGOs in La Paz to create working surveys. We met with PAHO, ARHC, Procosi, and other doctors and health professionals to review our instruments (surveys, interview guides, etc.). Revising everything was a lot of busy paper work. I learned that this is the probably the most important part of research, preparation and start up cost. I think it was Abraham Lincoln that said, “If I had five hours to cut down a tree, I would spend four sharpening my ax.” That’s how this study has been. I was so excited to finally be able to spend time in the clinics, hospitals, and with the people in their homes at the end of almost four weeks of doing nothing but busy paper work. But, those first initial few weeks taught me the importance of preparation. I am learning that with research, there is always start up cost. I spent much of the time in the hotel those weeks setting up a data analysis program. I was actually pretty proud of myself because I found a way to download the program to my laptop and I figured out how to use it all by myself. I thought that was pretty good for someone who is literally retarded when it comes to computers.

I felt many times as if I were in the MTC again, sitting around all day preparing to go the field. We did get to a couple of the medical clinics where would be working eventually. We met with a few of their doctors and learned how they work things around there. It was really interesting learning about how they treat different medical cases. In Bolivia there are three different types of hospitals. There are the clinics where babies are born, and where you would go for a normal checkup. There is usually one clinic in each little community. Level two hospitals are where you would go for a “C” section or other basic surgery. And then there are only a couple of level three hospitals in all of La Paz that do the specialized surgeries. We only worked in the clinics in the different communities.

Eventually after meeting with the various NGOs we were finally ready to start with the pre-testing in a clinic called Lotes. I was with Ben and Heather the entire day during this time. It was a great learning experience to know exactly what we needed to change with our surveys. We made some final changes with Kirk’s advice as well and started with the actual surveys two days later. I went to Atipires and Ben and Heather both went to Senkata. One thing I learned from the Lotes clinic is how rude the nurses treated their patients. One particular mother came in with her baby Diego who was extremely sick with pneumonia. The baby’s pneumonia was so advanced that one of the nurses immediately called an ambulance to transport the mother and the child to a level two hospital. After the nurse made the call to the ambulance, she criticized harshly the mother for mistreating her baby. She blamed the mother for not bathing her baby enough, a sign of neglect and the reason for her baby’s pneumonia. She basically belittled the mother until the ambulance got there. During this time we tried to interview the mother but she was so distraught over her baby that she did not even want to talk to us about anything. Over the next several weeks, I would learn that several mothers do not seek medical care in the clinics because of how badly they are treated there. It broke my heart, as I realized the only source for true help for pneumonia, the clinics, with access to life-saving antibiotics, shun patients away like this mother.

After our initial pre-testing was complete, I had a really good day the first day in Atipiris as I interviewed two mothers whose children had ARI pretty bad. The last mother I interviewed was an angel. There was something about her countenance and the way she treated her little three year-old son that touched me deeply. While in the waiting room before I met with them, the boy took one look at me and started to cry. I guess my white skin scared him pretty bad. But I gave him a piece of candy and actually made him smile afterwards.

That last interview that day made me a little bit late for my appointment with Heather and Ben at Senkata (we were supposed to meet at 4:30) to make it to a meeting with Adrianna at 5:30. So as I met with them a little after 4:30, I could tell that something had not gone right with their day. I found out quickly that they did not have a single interview all day, because they waited around from kids with pneumonia all day, and didn’t interview the kids that had bad cough and other signs of ARI. As I traveled back to Arcabucero that night with Heather and Ben, I had my first experience with severe negativity with the study. The negativity got to me so bad that I could not even sleep that night. We worked that day from 7:30am to 10pm (trying to contact Kirk late that night about several of the challenges we were facing). We all went to bed exhausted. I wrote my dad about the negative attitude of the others the next day. He wrote back some invaluable words of wisdom from his own experience. He told me, “Much of life is dealing with negative situations and learning how to deal with them and overcome them.” I valued that advice for the next several weeks as the study continued to be extremely hard. The reason I write about the negativity is not to bash the others on the study. But, I learned so much about how to deal with negative attitudes from working with them for several weeks. I think that the most important lesson I have learned over the past two months is how to work together with others, despite all our differences. Many in the group have noticed that I am always running at least five minutes late everywhere I go. So many people have had to find extra patience with this flaw during our time here. And I have had to learn patience dealing with others’ flaws as well. Learning patience with others despites their little flaws is an invaluable lesson that will serve me well for the rest of my life.

The following day I went to Senkata. It was a hard day, but I had three amazing interviews, one with a mom with a kid with serious pneumonia. As I interviewed each mother, I felt such an edifying feeling, helping their kids out. It was almost like teaching someone the gospel in Paraguay again. I felt a deep love and compassion for the mothers as they grieved over their sick children.

During everyone’s lunch break that first day in Senkata, I went looking for a kid in the community who came into the clinic a few days earlier. I found the street ok. But, as I was looking for the house number, four stray street dogs cornered me and kept getting closer and closer. I thought I was really dead meat. Even the rock I had in my hand did not even faze them. So I just backed up really slowly until they finally left me alone. I decided it might be safer to actually go with a Bolivian to find the kids in the communities after that incident. How grateful I was for Luciano, a dear friend in Senkata, who would later teach me how to deal with all the stray dogs in the communities.

After our trip to the temple in Cochabamba, our study picked up quite a bit. For the last weeks of our research in El Alto, I worked in the clinic Senkata from 9am to around 5pm every day. The mornings I would spend in “la sala de partos” interviewing mothers who would bring their kids in with ARI. The doctors in Senkata would bring to me all the cases of ARI except the common colds. Some mornings I would have four or five interviews, and other mornings I would have zero. It varied day to day.

As I interacted daily with the doctors, nurses, and administrative staff at Senkata, I developed a deep relationship with many of them. Luciano and I became friends as we went out in the communities each afternoon to do the follow up visits with the parents with kids with pneumonia. We became good friends through our different conversations those many afternoons as we biked many miles. His love for the mothers and their children was evident by the way he treated each one. Every case of pneumonia was so important to him. His example taught me to be more compassionate with the people as I eventually left to do the follow up visits by myself. In addition to his compassionate example, he taught me how to avoid being eaten alive by the ravenous dogs of El Alto. I asked him once, “Luciano, ¿cuántas veces ha sido atacado por los perros?” He responded with a smile, “Sólo dos veces.” I learned from him to get off the bike when a dog started barking loudly, and position the bike between my body and the dog, something that would save me from being attacked several times in the weeks to come.

In addition to interviewing the mothers, I also had many interviews with doctors. I learned so much about the practice of medicine in Bolivia just from talking to them about their different experiences as physicians. One thing that I admired from each doctor was that they absolutely loved what they did every day. It was clear that they cared so much for the poverty-stricken Bolivians, by the way they touched a shoulder, smiled at their patients, and were so lively about what they did. I loved interviewing all these doctors in Senkata. Besides the interview questions, we had wonderful conversations about their different practices and my own ambitions to enter medical school. We joked around quite a bit, and it was nice to see that each doctor had such a personable side to his personality.

As I developed a closer relationship with Dr. Lara, I invited him to a couple of peanut butter sandwiches one afternoon. He told me he had did not even know what peanut butter was. As he took his first bite, it was like a kid on Christmas morning examining a new toy that he had never seen before. He absolutely loved the peanut butter that I gave him. It was so fun to find something that I could this dear doctor. As we were talking that day, one of the nurses approached him about an emergency birth in the community that he needed to attend to. His look at me told me that he wanted another peanut butter sandwich for the road. So I quickly made up a sandwich for him and he ate it on the way to the birth. I couldn’t help but to smile at him. My last day in Senkata I bought a whole jar of peanut butter for Dr. Lara and wrote on the lid, “Dr. Lara, Gracias por todo! – Cameron” He thanked me so sincerely for my simple gift. I felt such an edifying feeling knowing that I could give something back to him.

One thing that touched me deeply in Bolivia was how willing everyone was to help us out. One Friday afternoon I asked Dr. William in Senkata if I could use a bike the following day to do follow up interviews in the community (the clinics aren’t open on Saturdays). So he walked me over to the little store across the street and introduced me to Eloy, asking him if there was any gasoline in the ambulance. Eloy was in charge of the ambulance on the weekends and he responded to Dr. William by saying, “Sí, Doctor. Hay bastante gasolina.” Afterwards, Dr. William asked him if he would be willing to take me around to the different homes in the community that Saturday so I wouldn’t have to bike it. I exclaimed to him very clearly that I would be fine if I could just use a bike for the day. But Dr. William and Eloy insisted that it would be fine to take me around in the ambulance. The ambulance and Eloy’s help saved me several hours the following day as we were able to find four mothers at home with their children. The Bolivians were so nice to us about accommodating us with whatever we needed. They did not even act like anything was an inconvenience. It taught me to go out of my way to help others.

Working in a clinic for several weeks, opened my eyes to the lack of sanitation that is so prevalent. I was grossed out every time I wanted to use the public rest room in Senkata- no toilet paper, no running water, nor soap to wash your hands after. I observed that even the nurses and doctors recycled their latex medical gloves, washing them in a sink for reuse. Throughout Senkata there was always a foul odor that lingered all the time. My clothes would absorb the smell as well, so I would have to live with the smell every time I wore the same clothes twice. I hated the smell. But, it reminded me of the extreme poverty that surrounded these people. I went home everyday to a nice hotel room with hot water showers. I had money to pay someone else to wash my clothes. But these Bolivians had nothing. They lived in tiny adobe homes, surrounded by tall adobe walls. They never experienced hot showers and due to the extreme cold no one could blame them for not showering very often. Yet I wonder how much of the disease they suffered from could be attributed to the lack of hygiene they lived in. I gained a new appreciation for soap and toilet paper and hygiene in general by working in the clinics in El Alto.

The past two months have been extremely rewarding for me as I have strived to work my very hardest to make this ARI study successful. Through my contribution to the study, I was able to interview about 40 mothers about their children with ARI, interview several doctors, finalize and format several surveys, download and set up the data analysis program Epinfo, amongst countless other hours of paper work. I can honestly say that I gave everything I had to the study. I strived to work my very hardest every day. Often times I would come back to the hotel at Arcabucero, totally exhausted, wanting only to go to sleep early. Only my mission in Paraguay can compare to how hard the work was- but also to the rewarding side as well. One afternoon as I was doing follow up interviews in San Sebastian, a little neighborhood pertaining to Senkata, I met with Teresa, a mother who had come into the clinic a couple days previously. As I entered her tiny yard surrounded by a large adobe wall, I sat down on a little bucket to interview her. At the end of the interview I asked her, “¿Tiene alguna pregunta ahora para mí?” She responded with a shy smile and said, “Sí, tengo una pregunta. Podrías ser el padrino de mi wawa?” I was not quite sure what she meant by “padrino” so I asked her what a “padrino” did. She said, “Pues, es como un segundo padre.” I told her that if she would meet me in the clinic the following day that I would be happy to be little Griselda’s godfather (“padrino”). It was an honor knowing that I was making a difference for a few of the mothers I interviewed. It reminded me many times of bringing the gospel message to the Paraguayan people. That made all the hours in the sun, thwarting all the dogs wanting to kill me on my bike as I looked for the mothers’ homes well worth it.

I have a very strong interest in medical care. Working amongst doctors and medical personnel for two months was often like Disneyland for me. Several times while I was working on the study on my laptop in the “sala de partos”, the doctors would rush in with a mother almost fully dilated, ready to have her baby right that second. It was fascinating to me that it did not ever bother them that a gringo sat right next to where all the babies were born, observing over the shoulder of the doctors there.

My grandpa was a physician in Provo until his death from a family genetic kidney disease in 1960. Many of his patients wrote after his death about his altruism- not billing his poor patients and always willing to look at a neighbor that was suffering from this or that. As many Bolivian mothers called me “Doctor” over the past two months, my thoughts often turned to my grandpa who I never knew. The trust in each mother’s eyes pleaded with me to do something that would help their babies to feel better. My heart ached with compassion for their mothers as I interviewed them. I long for the day when the results of our study will save more children’s lives, as more mothers seek adequate medical care for their children with ARI. My experiences with the patients, nurses, and doctors of Atipiris and Senkata cemented my desire to have a life serving underserved people in health care.