When I was in college I had frequent sinus infections. Shortly after arriving to San Antonio for each school break, I would make an appointment with my ENT. I knew to bring a good book with me and to be prepared for a long wait, sometimes up to two hours. It wasn’t how I would choose to spend my free time, but I knew that eventually I was going to be seen and get excellent treatment. In fact, he was one of the best ENT docs in town, which was why his office was so busy.
Imagine spending days or weeks waiting to be seen by a physician, with no hope that you will actually receive care. This is what life is like for poor patients in Bolivia; they have become masters at the waiting game.
The pediatrician at the nutritional center is a jolly fellow in his late 50’s. He likes pointing out interesting exam findings, shooting the breeze with the staff, spending weekends relaxing at his ranch, and asking me what Dan is up to and why he doesn’t come hang out with us at the nutritional center more often. And, he’s really great with the kiddos. But, like most physicians here, his practice of medicine is a reflection of an exceptionally large power differential between physicians and patients.
Specific appointment dates and times don’t seem to exist in the public hospitals and health centers here. In order to get a ficha, an appointment, for their child at the nutritional center, parents need to arrive at the center before 7 am. This often requires traveling over an hour on a micro. Patients are then given a number and told to wait. And wait they do. Around 9:45 am, the attending arrives from another hospital (an HIV hospital where he leads rounds, which is an entirely separate issue; physicians here are allowed to see patients outside of their specialty without needing special training). At 10 am, he joins the rest of the staff for a coffee and empanadas break. By 11, I’ve already sent Dan three text messages about how we still haven’t started seeing patients. At about 11:30 we do a quick assessment of the severely malnourished children who temporarily live at the center. Meanwhile, I’ve read the same book to Miguel about four times, played hide and seek with Rosario, tickled Meilin until I thought she was going to cry, chased Maria around, managed to become covered in food while trying to feed Ikerd, and read 20 pages in my novel (taking a year off definitely facilitates reading for pleasure!). Finally, around noon we start seeing the external consults. The last patient seen that day usually waited about 8 hours. To make matters worse, moms often come with all their children, and they don’t come prepared with diaper bags full of emergency supplies such as snacks, toys, and games to avert a total meltdown.
While the plight of poor patients saddens me, last week’s events left me angry and frustrated. On Monday, the attending arrived and announced that he had a meeting scheduled and was leaving early. Moms who had already been waiting over two hours were told to come back mañana. On Tuesday, he was again leaving early and could only see a few patients. Moms, many of the same ones from Monday, were told to come back mañana. On Wednesday, it was the attending’s birthday. He stayed long enough to eat an empanada with the staff and then left, with his birthday cake. Moms were sent home. On Thursday, there was a medical personnel strike, a frequent occurrence. This time physicians were protesting a government-imposed increase in work hours, from 6 to 8 hours. Dan and I were shocked when we first heard this; however, we later learned that many physicians who work for public hospitals and health centers augment their meager salary through private clinics. This law would impede their ability to do this. Patients all across the city were sent home that day.
Later that afternoon, while seeing consults, a mom walked in with her 22-month old daughter. The baby was clearly severely malnourished and had several classic signs of severe dehydration, including signo de pliegue, when dehydrated skin retracts very slowly back into place after being pinched. The attending immediately chastised the mother. Why didn’t you come sooner? Why haven’t you been feeding your daughter? You must be eating all the food! Come to find out, this mom had come both Monday and Tuesday and was sent away. No, this baby didn’t become severely malnourished overnight. And yes, if the mom was better educated, she might have known that her daughter needed to be taken to the closest hospital or clinic for IV fluids. But sending this mom away for two days was pure negligence and only hurt the innocent child.
On Friday, I took a group of the severely malnourished children to the lab at the public health center down the street for scheduled blood work. This is always a painful process because the kids are fasting, and we’re supposed to arrive with the kids by 7 am, but the nurses don’t start blood draws until almost 8. After waiting for an hour and a half with crying kids and perturbed moms, the laboratory personnel announced that they weren’t going to be taking patients that day because it was the 17th anniversary of the center. Exacerbated, I spoke with the head nurse, who convinced the lab personnel to go ahead and do the lab draws. I watched as a nurse hastily pocked and prodded for Meilin’s small vein. As we walked back to the center, one of the moms suddenly remarked, “Sometimes I feel like a toy.” I couldn’t have said it better myself.
This week is turning out to be strikingly similar to last week. Yesterday was father’s day in Bolivia, and it seemed that men across the city took the day off or part of the day off (or, like the guard at our complex, proceeded to drink on the job). And I just discovered that there is to be a medical personnel strike for the next two days.
I do appreciate the slower pace of life here, and I think it’s great that people can always find a cause for celebration. I also understand that physicians working in public hospitals here take a substantial pay cut. However, I really believe that physicians should be held to a different standard that other professions. In matters of sickness and health and life and death, I want a caretaker who is available and will advocate for me, and I imagine that the patients here would want the same.