Author: Sara Habibipour
For my second rotation, I stayed in the city. But, this time I went to the main, tertiary care center–El Hospital San Juan de Dios.
It was definitely a different experience than any other hospital I’ve shadowed at in the United States.
To quickly summarize the Bolivian healthcare system, under SUS (El Sistema Único de Salud) which was enacted by former president Evo Morales, all Bolivians are guaranteed free healthcare. This greatly expanded primary care centers (general clinics where you see just about any and all issues) but it also meant that you can see specialists in a tertiary care hospital for free. This means that hospitals are often understaffed in comparison to the large population that they must serve, but on a good note, it's accessible to everyone. For those who don’t want to wait, there are private healthcare centers where a consultation is typically around 20-30 Bolivianos, or about 3-4 US dollars. However, anything more than 10 Bolivianos can be a large expense for the lower and working classes, so many opt to use the free healthcare system.
In the most respectful sense, El Hospital San Juan de Dios was pretty chaotic. The lobbies and waiting rooms were filled with thousands of sick people, many of which were sleeping on the benches overnight waiting to be seen. Stray dogs were extremely common on the streets, but they also made their way into the hospital. Infrastructurally, the facilities were quite poor; the building was built in the 1980’s and nothing has been renovated since, so a lot of the ceiling panels were missing, there were holes in the walls, etc. The digitized medical record system was also not yet fully established; handwritten patient records were all kept in a metal binder, labeled by bed number. Doctors were constantly searching for files; oftentimes when they needed a file it would be on a completely different floor of the hospital and there was no way to locate it. However, the level of documentation seemed to be similar to the United States; most time was spent charting.
It was also really interesting to see that all pages among doctors and even CT images were sent via WhatsApp. X-rays, however, were still done traditionally, where doctors held a print up to the ceiling or window light. As long as a patient didn’t have COVID or another respiratory infectious disease, rooms often had 6-10 patients in them, so there wasn’t much patient privacy. In fact, this is something I noticed at the Chagas Clinic as well; doctors often sneak photos of patients without their consent and send them to whomever, especially if the patient has a compelling story. Of course, I don’t think there’s any ill intent; it’s just something that would get a doctor into a major lawsuit in the United States.
I primarily stayed on the internal medicine floor with a team of pulmonologists. There was lots of asthma and a few cases of elderly people with pneumonia and/or COVID. But unlike what you would typically see at a US hospital, there was a LOT of tuberculosis. There was actually one case of an older man with tuberculosis meningitis, which is rare both in the United States and Bolivia. The first day I saw him he was unresponsive and bed-bound; by the end of the week he was still unable to move, however he was interacting visually and verbally a bit more.
Nextdoor was a 91-year old man who was in respiratory distress; the doctors pulled back the covers to examine him and he was completely skin and bone; his rib cage protruded from the rest of his body; I had never seen anything like it. I had seen severely ill family members before, but really, I had never seen anyone that close to death. What I found different from the US was that there was no palliative care specialist in the hospital, even though there was just about every other medical specialist. Even though he was on his deathbed, there were no conversations with his family about end-of-life care, making him comfortable, etc. I figure this is because family values and views on life and death are pretty different between the US and Bolivia for various spiritual, religious, and cultural reasons. But, I’ll never forget the time when I was across the hall checking in on another patient; I was observing from the doorway since the room was already very crammed with doctors and family members. Something in my head kept repeating the name of the 91-year old man. I turned my head towards his room; the door was open, his bed was empty, and his belongings were gone. He had passed away. In that moment I felt a lot of different emotions; I wanted to cry because, from how I saw him the day before, I knew he didn’t die comfortably. But, at the same time, I was grateful that he was put out of his misery; I just hope that he wasn’t suffering as much as I saw him the day before, but that likely wasn’t the case.
I also saw a hantavirus patient. For those that don’t know, hantavirus is transmitted via rodent droppings, urine, saliva, etc. Hantavirus can cause two types of disease: hantavirus pulmonary syndrome or hemorrhagic fever with renal syndrome. Hantavirus pulmonary syndrome is most prominent in the Americas, and this was the case of a fourteen year-old, pregnant patient who came from a background of severe poverty. Her condition escalated quickly; early one morning a team rounded on her and said she had clear lung sounds, but by that afternoon they were hearing crackling sounds in her lungs. She was then moved down to the ICU. She was only in her second trimester of pregnancy, so they were concerned about what would happen with the baby. She became more stable later on in the week and was moved back up to the internal medicine floor, however I’m not sure what ended up happening with her pregnancy.
Overall I saw some infectious disease cases at this hospital that I wouldn’t be able to see on a regular basis in the United States. This rotation also really threw me into the reality of the everyday hustle and bustle of the Bolivian universal healthcare system. I’m grateful to have had this experience, and looking forward to comparing it with other global health experiences in the future.
Note: Sorry I don't have photos for this article! But, I'll have more in pt.3.