Comparative Health Systems 101

Part I: How we ended up at the hospital (in a meandering sort of way):

We spent two nights in the small city of Jujuy, Argentina before lugging our backpacks to the bus station at 7am to catch a 2 hour bus ride north on unpaved Highway 35 to the miniscule town of Tilquiza. The town consisted of a tiny cement schoolhouse – painted a couple of shades of garish turquoise which reminded me a lot of the colors of Hawaii public school buildings. Our plan was to stay for a week on a small private organic farm and self-described nature reserve, owned by a family of three – Martín, his wife Elizabeth, and their 12 year old son Matíus. They had run a hostel/b&b in a very rural part of Ecuador for a number of years, and bought this parcel of land – 950 hectars that borders on semi-national forest – to live out their dream of living off the land and running a nature reserve for visitors.

As soon as we hopped off the bus, Matíus was there to meet us and guide us over to his dad and their truck. We threw our backpacks in the back and rode the 30 minutes from the highway to their secluded parcel, across a shallow river, over the hills and fields of the neighboring cattle ranch, through about 8 cattle gates until we reached their land. They mentioned to us that we were lucky because it hadn’t rained in a few days – if it had rained we would’ve had to hike the 1.5 hour hike through boggy dirt roads that become impassable to their truck. After parking the truck, we crossed another shallow river and then hike about 15 minutes or so up an embankment to their house. The land was incredibly lush and moist and incredibly beautiful.

(Rebecca hiking the final steps up to the reserve on day 1.)

(View from above, looking down onto the 4 buildings that they built – seen in the center clearing. One is a house for them, one a kitchen and dining room, and two are bunk style guest houses.)

(They have put in 4 well-marked trails for their vistors, that allowed us to safely take hikes around their land.)

The nearest neighbors’ houses were 45 minute walks away. A couple of days into our stay, I wanted to buy some eggs for protein, which involved walking for 1.5 hours to the "store" which was really a very very old man’s house with a grate over one window through which you could order things. Except he only had a few eggs from his chickens. I ran into a man on the way back who told me that he thought another neighbor would sell eggs too. Sure enough, I found the man who runs the cattle ranch for the owner, driving his tractor along the road back to the reserve. I hopped on the back of his tractor with him back to the barns and bought a dozen and a half more eggs, and then walked the hour or so back home.

(Baby lambs I saw en route to egg buying.)

Martín and Elizabeth had a good sized vegetable garden going – but it was definitely in its infancy. They were still trying to solve the problems of how to deal the clay filled soil and how to deal with the super moist climate. They had originally tried to follow more strict permaculture practices, but were having to majorly improvise. Nonetheless, they had a ton of greens, carrots, squashes, corn, tomatoes, peppers, beets, radishes, and herbs – all growing on tiered terraces down the side of the hill.

Our main task for the week was to build another level terrace. Definitely hard manual work, but we were excited about it – we’d been feeling pretty slovenly for several weeks and hard exercise felt good.

(Rebecca sitting with the pickaxes and shovels…)

Elizabeth and Martín also have 9 chickens which had been rescued from an egg factory where they had been severely maltreated – so they were kind of a motley crew on the whole and were not big producers anymore on the egg front.

(One of the plusher looking chickens. There had been 20 chickens but one of their five dogs, "Salta", apparently had a penchant for chickens, leaving us to ponder somewhat whether being “rescued” was really the right word for their plight…)

Salta, the dog, was one of 4 other dogs and her three adorable puppies that shared their farm with two elderly horses whose job it seemed was to cut the grass.


Martín and Elizabeth’s dream is a beautiful one, to live on their land with like-minded community and preserve the gorgeous forest in their midst. However, they are a bit zealous in their beliefs and have yet to find anyone who wants to live in the same somewhat austere manner and who shares their values around food, sustainability, living off the land, and western medicine. Their lives are pretty isolated and their strong beliefs against cattle ranching have needless to say created some tensions with their cattle ranching neighbors. Their son Matíus is largely homeschooled because the 1.5 walk to and from school is a bit much. He’s extremely intelligent and well read but we couldn’t help feeling a little sorry for his isolation – his social world revolves around travelers like us coming to stay on the farm for a week to a few weeks and then leaving.

But nonetheless they have created something amazing in its own right. We took a hike with them to the shack of an 85 year old man who has been living on their land long before they bought it. They are extremely kind and from time to time drop in to check on the man and give him some extra groceries to supplement his meager lifestyle.

Along the way we saw gorgeous wildflowers, air plants, wild orchids (unfortunately not in bloom), ginormous anthills, and bizarre-o catepillars (yes those are all catepillars -- the hairy ones sting you!)

…

Then all of sudden, everything got less fun…

Rebecca came down with a fever that quickly climbed to just under 103, and stayed there. Being in the middle of nowhere stopped being relaxing and started feeling a little scary – especially knowing that if it rained again our only option would be to hike the 1.5 hours out by foot, and then take a 2 hour infrequent bus ride back to Jujuy. When Rebecca started feeling like her kidneys were hurting we decided we needed to go. So I packed up our two bags, we hiked down the hill and across the shallow river to the truck, and at 9pm Martín drove us to a hotel in Jujuy. It was 2 days before Easter – and Semana Santa is a big deal here – so the only hotel we could find was a crappy expensive one. But, it was only 2 blocks from the hospital. We took Rebecca to the emergency room and, after receiving hands-down the most painful shot of her life (to bring down the fever), they sent her home with some antibiotics … that didn’t work.

Two day later she was being admitted to the hospital because her fever had not broken. The good news was I had hopped onto the internet and found us a new place to stay.

Rincon del Valle is a little bed and breakfast which, if you ever find yourself in Jujuy, I can’t recommend enough. The owners, Pablo and Andrea, were some of the nicest people we’ve met on this trip – and during a moment that was scary and hard, they definitely helped us feel like someone was looking out for us. Not to mention that their place is gorgeous and tranquil. It’s located on the edge of town less than a 10 minute (very inexpensive) cab ride from the center – but in Jujuy it’s nicer to be on the edge of town anyhow. Most people come here for incredible scenery near the city, not the city itself. Unfortunately we didn’t see much more than the hospital and the few blocks around it – so having a "home" to go back to was so appreciated. They were even getting ready to come visit Rebecca in the hospital when I finally took her home. They had yummy homecooked dinners available, homemade bread and jam every morning, a gorgeous kitchen to use, and our room was big and bright and sunny and overlooked the garden. Pablo is a preschool and kindergarten P.E. teacher and Andrea spent several years working for a local organic farm. We ended up staying with them for a full week. It felt so cozy and comfortable that after the traumatic events of the week, it was hard to make ourselves leave.

There was also a really cool fellow from Italy staying them. He said he likes it there so much he’s renting his room for his 2-year stint working with the government of the province of Salta. The government contracted with his company to experiment with growing amaranthe in the region – a grain a lot like quinoa but smaller and equally packed with nutrients. Amaranthe is considered a “whole protein” – one of the extremely few foods, other than meat, that gives your body everything it needs in terms of protein (usually you must combine grains and legumes to get "complete protein" ... or eat meat). With meat being more and more expensive in Argentina, the government of Salta wants to introduce a nutrient rich grain to the region. His company is experimenting with all kinds of strains and hybrids over the next years to find one that is perfect for the region. One evening Rogero came home with amaranthe greens to share for dinner – which Andrea turned into one of the most amazing savory tarts ever. Amaranthe greens have a mild flavor like spinach but are a little hardier, more like chard, and are officially my new favorite green.

(Here is one of Rogero’s bunches of amaranthe. Apparently there are varietals that produce better greens and varietals that produce better/more seeds. This is the seed kind. We are determined to try to grown the greens kind back at home – if the climate permits…)

Part II: Hospitalization in a foreign land

(Rebecca’s very sparkly internal profile. No doubt about it – she’s got good bone structure. But I’m concerned she may have black lung, and leaves growing in her belly.)

The phlebotomist leaned over me, needle readied, my arm prepped with vein enlarged by the rubber tie, my breath held. Just as I made myself relax so she could insert the needle, she paused. "This test is going to cost 67 pesos. When are you planning on paying it?," she asked. I reassured her, "mi esposo va a pagar cuando el regressa," (my husband is going to pay when he returns). Satisfied, she went on with her work. Thereafter, every time Blake was in the hallway, someone was asking him to pay a bill. But I'm getting ahead of myself. I´ll start at the beginning.

As Blake gallantly packed our things in the cabin on the farm, I tried to sit on the bench outside of the cabin. However, keeping myself in a sitting position proved too difficult, and I lay down on the ground instead, occassionally swatting at the moth that had taken an interest in me. By the time we got to the truck -- after the walk in the dark about the length of a football field -- my head was spinning and I propped myself against the truck until finally I could sit down inside, which felt like a miracle. When we got to the hospital in Jujuy, the nurse checked my vitals. She seemed unsure about what my temperature was. Every time I asked, she gave me different unclear answers. However, she and the doctor (who did not seem so jazzed to be working, didn't examine me, and was extremely cocky) deemed me appropriately feverish for some antibiotics and a very painful injection to lower said fever. No one at the hospital spoke English -- or slow clear Spanish so we could understand -- so thankfully Martin stayed with us and acted as translator. For my part, I couldn't focus enough to understand anything. I know that Blake wants to learn some medical Spanish, but I think there are some more enjoyable ways to do it. Off we went, with the hope that we wouldn't see the hospital anymore.

One and a half days later, with my fever still persisting, we returned to the hospital. We were unbelievably relieved to find that the doctor on duty was much more attentive, and actually cared whether we understood what he said. He told us that he would be there until 8pm, and that we should come back if the fever did not break. Back we came at almost 8, worried that it would be very difficult to get care the next day, which was Easter. They did an ultrasound to make sure my organs weren´t inflamed, and I was admitted to the hospital for fear that I had dengue fever (I didn´t), and also to get an IV for fluids.

The nurse who put in my IV got my vein on the first try. Kinda. Actually, she missed my vein, but decided just to turn a corner to get it, instead of trying again. My veins are really easy to find. However, I still have irritation in my arm 3 weeks later (although it´s been checked, and it's nothing to worry about). When she did get my vein, before she connected the IV tube, blood started pooling out, and a stain twice the size of a quarter formed on the sheet before they got it under control.

I found it quite alarming that no one asked me anything about my health history, whether I was on any medications, whether I had AIDS or whether there was a possibility I was pregnant the whole time. They just started pumping me with fluids and antibiotics and some other stuff. I would know to speak up about these things, but not everyone would. It was the beginning of realizing how much we take for granted in our health system.

The hospital felt stuck in the 1970's. There were little things, like in the bathroom, the toilet paper rolls weren't on spools, just stuck between the wheelchair access pole and the wall, so each time you used it, you had to put your hand inside the core to take paper. The IV pole didn't have wheels, so each time I wanted to use the bathroom, I had to lift the entire thing, and carry it with me as I shuffled to the bathroom. Which was quite comical actually, but I'm not sure what I would have done had I been in a weaker state. I never saw anyone actually put on latex gloves, although they seemed to have them.

The medical staff was well trained and did their jobs well, but in some common sense ways, the support staff was not so attentive. Someone brought me dinner, and put it on the wheeling table, which was at the foot of my bed, then left without making sure I could get to it. With the IV, I couldn't reach it, and Blake was out on an errand. Thankfully, my roomate's mom was there. My roommate there was an 18 year old girl who had an as yet unidentified intestinal illness after 6 months of being in and out of the hospital. She was alarmingly skinny, and she was waiting for her insurance to approve a move to Buenos Aires where she could get better care. Her parents were with her 24 hours a day, sleeping in a lawn chair they had brought from home at night, watching TV all day. When the worker brought me dinner, without me asking, her mom immediately elevated my bed for me, brought the table to me, and made sure that I could comfortably eat the food. She kept watch over me the whole time I was there, whenever Blake was out. I felt incredibly lucky that someone had my back.

Despite all of this, my stay in the hospital was very helpful. Between the fluids and the antibiotics, I was feeling much better after two nights, and got to go "home" to our sweet bed and breakfast, more antibiotics in hand (another full course), and after several days of recuperation, when my energy was getting stronger, we decided to head on to Sucre, Bolivia to take Spanish classes.

The first morning in Bolivia, in transit from Jujuy to Sucre, I woke up in our hotel room with a strange rash on my legs. By the end of the day it was covering my whole body, and the next day it moved up to my face. The school recommended a private hospital, and I went the first afternoon. I was initially very impressed by the cost to consult a doctor - the equivalent of $3. However, lesson learned, you get what you pay for -- and with medical care what you get matters. I told the doctor the whole story. In Spanish. In perfectly fine Spanish. People kept coming into the office to ask him questions. I think he was the head doctor. He said, "It´s a food allergy." "I don´t think it´s a food allergy," I said. "It's a food allergy," he said again, and prescribed me a shot of Allerfen (a mega antihistamine). "I took an antihistamine last night, and it didn't do anything," I said. "It's a food allergy," he repeated. "If you don't get this shot right this minute, you will stop being able to breathe." Well jeez, what was I supposed to say? In hindsight, I think "Thanks but no thanks"would have been the correct thing to say. However, with fear that I might stop breathing, and kind of being a fan of breathing, I took the shot.

The nurse who administered the shot was kinda tired. I could tell because she kept yawning. She made small talk with me so I'd relax a bit. Which helped, I'll admit. Afterwards I asked her how long it would take for the medicine to take effect. "Two or three minutes," she said. I was skeptical, but she told me to hang out for a bit. After a couple of minutes, she assured me that it was starting to work. I went to look in the mirror in the bathroom. "No it's not,"I said. "Yes it is," she said, and yawned. The doctor came in. I asked him how long it would take. "A couple of hours," he said. I left. The shot did nothing.

That night we ran into a friend who we'd met back at the farm near Jujuy. We had just been talking about her, because she too had had a rash, and it had been a food allergy. So it was quite strange when she walked into the restaurant where we were having dinner. Turns out this was her first time out of her hostel since being discharged from the hospital after passing out unconscious from salmonella poisoning. She, however, had found an excellent doctor. Who spoke English (and it turns out German and French as well) fluently, and fixed her up right good. Relieved, we took his info. A few days later, I was in his office, telling him my story.

Dr. Delgadillo was born and raised in Sucre, but went to medical school in Belgium, and worked in Germany for many years. He is a character in all the best senses of the word. He knows more about U.S. history than either Blake or I do (and both of us took college level U.S. history courses), and loves to talk about it and his travels. Our friend Angela (who is Swiss German) came with me to see him, since she had been having digestive troubles, and he did in fact switch between English and German with total fluency. He listened to us very intently. He laughed with us, he comforted us, he made us feel competely confident that we would be fine. He said, "Well, it's clear like water -- You're having a toxic reaction tothe antibiotics." He ran blood panels on my kidney and liver to make sure they were doing ok, and started me on a course of cortocoids for the rash, and dextrose to flush my liver. (The doctor at the hospital had given me antihistamines, but at the time, I was still taking the antibiotics, which is why it hadn't done anything.)

The rash is now gone, I am all better, and out of the experience I got to do a portrait session of Dr. Delgadillo, in his very Bolivian office. (I will post some photos later.)

One of my spanish teachers this past week was explaining to me that although she has insurance through the school, she never goes to the doctor that the insurance pays for because she doesn't trust the quality of them. She chooses instead to go to a private doctor who charges 100 bolivianos, which is less than my copay at home, but is quite a bit for people with steady professional jobs here. People here tend to rely on home remedies and go to the doctor only if they really have to. Those of us with the privilege of health insurance in the U.S. take certain things for granted, although I know there are exceptions to everything. Those without health insurance have experiences far worse than mine in Bolivia - like the epidemic of hospitals dumping poor people on the streets in their hospital gowns with their IV needles still in their arms because they can't pay and the hospitals no longer feel like providing the healthcare that is required by law -- if not by basic human decency. Still, if you have decent insurance, you will be treated with care. Hospitals are hygienic almost to absurdity. Doctors are sometimes (though fortunately not usually) very cocky and don't like to be questioned or wrong, but on top of the hypocratic oath, they have malpractice liability to keep them in check -- and centuries of case law to back things up (Bolivia has a brand new constitution with a whole lot of unanswered question in it). Although they produce lots of waste for the landfills, latex gloves are always used to protect both the patients and the practitioners. IV poles have wheels.

My care was overall fine, and I am back to my usual healthy self, continuing on our grand adventure. When I get home, I will go to the doctor and get blood work done again to make sure everything's good. I am a person of education and privilege. When you're sick, you feel vulnerable. When you don't speak the language or know how the system works, you feel even more vulnerable. I experienced that. With money on your side, you have some leverage, and really had I needed to, I would have had the out of using our travel insurance to get flown to Buenos Aires or home for better care. I never felt in danger. My experience made me imagine going through the health care system in the U.S. as a foreigner without resources and with poor English. Or going through the healthcare system here in Bolivia as a campesino who only speaks Quechua and has no money and has to rely on crowded public hospitals that are free but have problems.

I believe without question that we direly need healthcare reform in the US, that healthcare is a human right and should be universal, safe and accessible to all. Here there is a lack of training, quality control and access to medical resources, but services are free or inexpensive. In the US we have amazing training and resources, as well as checks and balances, for our healthcare professionals at all levels, but we have private health insurance companies that value profit over peoples' lives and often impede care. The bulk of the free services we do have, like emergency rooms, are last resorts. My experience has only cemented for me how important access to good healthcare is. We have every tool we need in the US for an amazing healthcare system for all, but we need to remove the blockades that perpetuate class inequalities and allow people to die or fall into dire financial straits for lack of funds while someone else in the same facility is receiving a full body MRI for hypochondria. I don't know what the solution is - probably a combination of government and private solutions, but in this arena regulation is clearly needed.

The other night over dinner with some friends from different parts of Western Europe and a friend from Bolivia, we were talking about taxes. Our Bolivian friend said that in general people pay 10-15% on income with the insinuation that it's too high. I said that in the US we pay 30-40%. She said very emphatically that it's not the same thing. Here they have no idea where their money goes - they don't get services in exchange, the money goes to government corruption. Evo Morales's government is wildly unpopular among the people that we've spoken to, and the accounts of corruption are scary. We have yet to sort through the information. We are only talking to educated middle class people in the city, not to the campesinos. I have been given lots of pause for thought about healthcare systems and assumptions about socialized medicine magically being great. Before we came here we couldn't really imagine what the healthcare system looked like. We'd heard good and bad about healthcare. Good because it is a 3rd world country that has attempted to put resources into its free healthcare system. But nonetheless it is a country that suffers from massive corruption, frequent political instability, a huge chasm between the small percentage of middle and upper class people and a vast majority in dire poverty, and very different standards of acceptable care than we've grown accustomed to.

We're still sorting it all out. Meanwhile we're looking for some good reading that breaks down what's currently happening in Bolivia politically. We have many puzzle pieces at the moment, but none of them fit together. If you know of anything good, please let us know!

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