News from Bolivia via Emily Moody (MP4)

Posted on behalf of Emily Moody, Medicine Pediatrics 4th Year Resident

Saludos desde Bolivia! I’ve been here two weeks, and it feels very familiar; even though it’s been 16 years since I lived in Santa Cruz (when I was a Rotary Youth Exchange student in high school).

The clinic here in Chilimarca was started about 30 years ago under the support of MAP, an international Christian health aid organization.  Jose Miguel deAngulo is the MD who came to run it in the mid-1980s (not sure exactly when). He and his wife Stella (who is a psychologist and program director) are Colombian, but moved here from the US where he studied public health at Johns Hopkins.  They raised their 5 children here at the clinic site, and home schooled them here.  The clinic is a primary care/urgent care clinic that provides basic vaccines, health visits, and has a basic pharmacy.

The scope of their work has changed over time. MAP initially supported a lot of outreach programs, including health promoter education for rural communities in addition to the functions of the clinic itself.  They had a very robust program educating “promotores de salud”, that reached many people. Initially it was 100% men from rural communities who participated in the program, but they ran into some problems with the men becoming very respected in the communities that some of them took advantage of their power and took advantage of young women in the communities (you will see the violence, machismo, and sexual violence themes return). So they started educating couples together, and also increased recruitment of women.  It took time for the communities to be willing to send women (they thought they were not able to learn the material, as women generally only completed a couple of years of school, and men completed a few years more), but it was very successful. In the last years of that program, they had 50% or greater participation of women.  They recently had to stop the program, because MAP re-organized priorities and was no longer able to support anything except the clinic itself.  In all, there are still >1500 rural health promoters in the surrounding communities that were trained here.

The women's group in Patamorochata in front of two houses: the white one was recently improved with plaster and cement as part of the Chagas control program, and the adobe one is how the house was previously.  On the far right is Stella Losada, the program director (and wife of Jose Miguel de Angulo, the local physician at the Chilimarca clinic)

Under MAP, they also started multiple other public health programs. One focused on increasing knowledge and community promotion to take care of children (also adults, but mainly children) with disabilities. It included some rehab, OT and PT some education on making and providing appropriate support devices, and a lot about education about differences. This was around 2000-2012, and this program has also been cut back by MAP.  It does still run, but is smaller.

They also have a Chagas program, for which they contract with the government to do Chagas screening.  The state program relies on people to come in to a clinic (in a city) to get tested, which is very unrealistic for a number of reasons. There is not a culture of primary care or well-checkups, so that is not an opportunity to do it. Many people from the rural communities believe that if you take somebody’s blood, then you have power over them to do witchery, so they will not make the trek to the city to give their blood – it would be ridiculous. So this program does outreach to rural communities. They do on-site education about Chagas, show what the vicuña bug looks like and how to repair holes in the walls to prevent them from living, and over time they establish trust to do the blood tests.  In a recent campaign in one rural community they had 14 positives. Those who screen positive then are referred to the central laboratory for confirmatory testing.  This program now has independent funding for the next three years.

The MAP clinic is still running. They have an 8am-10pm urgent care clinic run by nurses, 7 days a week. In the afternoon weekdays a general medical officer (MD from Bolivia, no residency) staffs a clinic also. They see anyone who comes through the door, with no charge.  They also have a dentist who works weekdays and a pharmacy on site with a well-stocked formulary.  Through the clinic they also do vaccines for children, as well as rabies vaccines for dogs.  Rabies is definitely here, in dogs and bats mainly. In Cochabamba last year, one nurse tells me they had >30 cases in people from dog bites.

The other large programs they run (sexual violence against children and infant mental health promotion and education) are entirely independent of MAP. Over the years of living in this community, they have come to see that there is a lot of violence inherent in society and specifically against women and children.  Within families and schools, children are hit regularly.  Sexual violence against women and children is also very common. Corruption within the police and courts is terrible, making it nearly impossible for victims of violence or sexual violence to seek justice.  The family (Jose Miguel and Stella) at this time are working to narrow their energies and focus their efforts on these two programs, because they feel that there are such deeply rooted societal problems that end up holding back children from developing their full potential, and that keep women from advocating for themselves and their children, that the other health projects don’t make the difference that they see can be made through their sexual violence and infant mental health work.

In Morochata with Dona Berta (the president of the local women's group and a health promoter) with
her 1 yo son Yoel and 9 yo daughter Sarah, and with Jenny, a lawyer who works in the rural communities as an advocate
for children and women who suffer sexual violence

As I mentioned earlier, Stella and Jose Miguel raised their family here. The kids were homeschooled here and enjoyed school and learning. The children’s friends from the community talked about the rote memorization and punishment that they suffered at school, and the kids were appalled – and one of the daughters made it her mission to start a school where other kids could enjoy learning as much as she did. They did it, and have a school for 6 mo to about 7 yr right next to the clinic.  It is a great place – they employ a lot of Montessori philosophy and have a garden and chickens, and do a lot of different kinds of hands-on learning. The school is also focused very much on involving parents, and providing a classes and instruction on child development and mental health – emphasizing attachment and security within the family.

With Daimar, a 4 yo with CP who receives services through the outreach programs for children with disabilities. 

One of the children in the family was then the victim of sexual violence. After she was able to tell her family, a long series of very difficult events followed that included trying to prosecute the perpetrator. They found that the society and judicial system are entirely set up (from mothers at home all the way to the courts) to blame the victim. Unequivocally. They struggled for a long time to get a lawyer who would actually advocate for them, and to get judges to hear the case. There were no resources available for the victim or family. So they started FUBE (Fundacion Una Brisa Esperanza) that advocates for victims of sexual violence. They have a building in central Cochabamba (Centro Una Brisa Eseperanza, or CUBE) where their activities are centered. They provide counseling services (they have 4 psychologists), legal services (4 lawyers), provide community and support for victims (who are ostracized by their communities after revealing the abuse), they do research, a lot of community education (to general public, police, judges, lawyers), they work for judicial reform.  They do a lot. The daughter who started this went to grad school for psychology and she and her husband went to law school, so they have part-time professorships at the Rutgers Law School and live half of the year here working for FUBE and half of the year in Philadelphia to teach, write grants, etc. They also do courses for US students to come here and learn about human rights law and judicial advocacy (for law students) and the health system (for nursing students). They currently do about 3 trips per year with 15-25 students (either law, nursing, or an interdisciplinary group) for 1-3 weeks each.

As I said, the main passion of Jose Miguel at this time is infant mental health. Between the machista culture, the violence, etc he sees that few babies establish secure attachment with parents from an early age. They focus on the first 1000 days (including gestation) as the most critical time for brain development and allowing the child to develop its full potential. They are planning to start programs including home visits, community education, and education within the schools.

For my clinical time, I have been working with Freddy (the clinic doc) to see patients together and do some pediatrics teaching. I’ve ordered a Harriet Lane in Spanish for them. I will also spend some time with the nurses in the urgent care when the clinic is closed.


The public health part of all of this is the most exciting to me. Since my area of public health experience is in environmental health, I’m working on developing a home safety checklist as well as a longer guide for home visits surrounding environmental health.  It has been fun, because the housing, city organization, and potential risks are quite different from those at home.  By the end of my time here, I also hope to have a presentation put together to do a sort of training or short course about environmental health.  I’m excited about the possibility that this will fit into and support the work they have already started.  Their model for the 5 main determinants of infant mental health include: physical development, socio-emotional development, cognitive development, development of auto agency, and safe and enriching environments.  My work will all be focused on that 5th determinant.