Results and evaluation of the expansion of a model of comprehensive care for Chagas disease within the National Health System: The Bolivian Chagas network.

BACKGROUND: Most people with chronic Chagas disease do not receive specific care and therefore are undiagnosed and do not receive accurate treatment. This manuscript discusses and evaluates a collaborative strategy to improve access to healthcare for patients with Chagas in Bolivia, a country with the highest prevalence of Chagas in the world. METHODS: With the aim of reinforcing the Chagas National Programme, the Bolivian Chagas Platform was born in 2009. The first stage of the project was to implement a vertical pilot program in order to introduce and consolidate a consensual protocol-based healthcare, working in seven centers (Chagas Platform Centers). From 2015 on the model was extended to 52 primary healthcare centers, through decentralized, horizontal scaling-up. To evaluate the strategy, we have used the WHO ExpandNet program. RESULTS: The strategy has significantly increased the number of patients cared for, with 181,397 people at risk of having T. cruzi infection tested and 57,871 (31·9%) new diagnostics performed. In those with treatment criteria, 79·2% completed the treatment. The program has also trained a significant number of health personnel through the specific Chagas guidelines (67% of healthcare workers in the intervention area). CONCLUSIONS: After being recognized by the Chagas National Programme as a healthcare model aligned with national laws and priorities, the Bolivian platform of Chagas as an innovation, includes attributes that they have made it possible to expand the strategy at the national level and could also be adapted in other countries.

The embodiment of water insecurity: Injuries and chronic stress in lowland Bolivia.

Water is critical to health and wellbeing. Studies have theorized that problems with water can become embodied, yet few studies have quantified this. Therefore, we first sought to understand the lowland Bolivian water environment of Tsimane' forager-horticulturalists. We assessed the water environment holistically, using objective measures of water quality and water services (Joint Monitoring Programme's drinking water services ladder) and subjective measures, including perceived water safety and water insecurity experiences [Household Water Insecurity Experiences Scale (HWISE)]. We tested how water service levels, perceived water safety, and water fetching frequency were associated with HWISE scores using Tobit regression models among 270 households. We then tested if and how water becomes embodied via self-reported water-related injury and a chronic stress biomarker, hair cortisol concentration (HCC). Results demonstrated that, compared with households using surface water, households with basic water services had HWISE scores 1.59-pts lower (SE = 0.29; P < 0.001). Ingestion of water perceived to be "bad" and more daily water-fetching trips were associated with higher HWISE scores. Twenty percent of households reported prior water-related injuries, with women most commonly injured. In logistic regressions, each point higher HWISE score was associated with 28% (95%CI:1.16-1.41; P < 0.001) higher odds of injury. Basic water services compared to surface water was associated with 48% lower odds (OR = 0.52; 95%CI:0.33-0.82; P = 0.005) of injury. Finally, using linear regressions among 332 adults, HWISE scores were not associated with HCC. Past water-related injury was associated with higher HCC (Beta = 0.31; SE = 0.09; P = 0.029) among women, but not men. Relying on unimproved water services compared to surface was associated with 46.2% higher HCC for women (Beta=0.38; SE=0.14; P=0.048) and 55.3% higher HCC for men (Beta=0.44; SE=0.15; P=0.044), respectively. Overall, our findings demonstrate that water insecurity can become embodied through water-related injuries and elevated HCC. Improving water service levels through an equity lens may help ameliorate water insecurity and its accompanying negative health effects.

Scaling down of a deworming programme among school-age children after a thirty-year successful intervention in the Bolivian Chaco.

OBJECTIVE: Preventive chemotherapy is the WHO-recommended control method for soil-transmitted helminthiases. In the Bolivian Chaco, 6-monthly single-dose mebendazole delivery to school-age children achieved a dramatic decrease in soil-transmitted helminthiases prevalence between 1987 and 2013. Consequently, in September 2016, preventive chemotherapy delivery was interrupted in nine rural communities. In compliance with WHO recommendations, we intensified surveillance to monitor soil-transmitted helminthiases prevalence and detect potential changes that would require interventions. METHODS: We conducted two cross-sectional parasitology surveys 12 months apart (September 2016-2017) among school-age children living in the communities where preventive chemotherapy delivery had been halted. Study design, methods of sampling and sample analysis technique (direct microscopy, Kato-Katz technique) followed WHO recommendations, aiming to obtain data representative of the Bolivian Chaco ecological zone. RESULTS: We collected 426 samples in 2016 and 520 in 2017. Soil-transmitted helminthiasis prevalence was unremarkable: 0.7% (95% CI 0-1.5%) in 2016 and 0.8% (0-1.5%) in 2017. Conversely, the prevalence of tapeworms (13% in 2016, 12% in 2017) and intestinal protozoan infections (81% in 2016 and 75% in 2017) continued to be high. CONCLUSIONS: Our findings support the role of preventive chemotherapy in reducing soil-transmitted helminthiases transmission, as otherwise poor hygienic and health conditions persist in the Bolivian Chaco. A national survey, involving areas from all the ecological zones of Bolivia, is now warranted.

A strategy for scaling up access to comprehensive care in adults with Chagas disease in endemic countries: The Bolivian Chagas Platform.

BACKGROUND: Bolivia has the highest prevalence of Chagas disease (CD) in the world (6.1%), with more than 607,186 people with Trypanosoma cruzi infection, most of them adults. In Bolivia CD has been declared a national priority. In 2009, the Chagas National Program (ChNP) had neither a protocol nor a clear directive for diagnosis and treatment of adults. Although programs had been implemented for congenital transmission and for acute cases, adults remained uncovered. Moreover, health professionals were not aware of treatment recommendations aimed at this population, and research on CD was limited; it was difficult to increase awareness of the disease, understand the challenges it presented, and adapt strategies to cope with it. Simultaneously, migratory flows that led Bolivian patients with CD to Spain and other European countries forced medical staff to look for solutions to an emerging problem. INTERVENTION: In this context, thanks to a Spanish international cooperation collaboration, the Bolivian platform for the comprehensive care of adults with CD was created in 2009. Based on the establishment of a vertical care system under the umbrella of ChNP general guidelines, six centres specialized in CD management were established in different epidemiological contexts. A common database, standardized clinical forms, a and a protocolized attention to adults patients, together with training activities for health professionals were essential for the model success. With the collaboration and knowledge transfer activities between endemic and non-endemic countries, the platform aims to provide care, train health professionals, and create the basis for a future expansion to the National Health System of a proven model of care for adults with CD. RESULTS: From 2010 to 2015, a total of 26,227 patients were attended by the Platform, 69% (18,316) were diagnosed with T. cruzi, 8,567 initiated anti-parasitic treatment, more than 1,616 health professionals were trained, and more than ten research projects developed. The project helped to increase the number of adults with CD diagnosed and treated, produce evidence-based clinical practice guidelines, and bring about changes in policy that will increase access to comprehensive care among adults with CD. The ChNP is now studying the Platform's health care model to adapt and implement it nationwide. CONCLUSIONS: This strategy provides a solution to unmet demands in the care of patients with CD, improving access to diagnosis and treatment. Further scaling up of diagnosis and treatment will be based on the expansion of the model of care to the NHS structures. Its sustainability will be ensured as it will build on existing local resources in Bolivia. Still human trained resources are scarce and the high staff turnover in Bolivia is a limitation of the model. Nevertheless, in a preliminary two-years-experience of scaling up this model, this limitations have been locally solved together with the health local authorities.

The production diversity of subsistence farms in the Bolivian Andes is associated with the quality of child feeding practices as measured by a validated summary feeding index.

OBJECTIVE: To determine the validity of a summary infant and child feeding index (ICFI) and the association with the index of factors related to agricultural production. DESIGN: A cross-sectional survey in eight health-post jurisdictions identified as priority nutrition regions. All households with children aged 6-23 months in eligible communities were administered an integrated survey on agricultural production and nutrition-related practices. Quantitative 24 h dietary recall, food frequency data and anthropometric measurements were collected for each child. Ninety-one per cent of eligible families participated. SETTING: The northern region of the Potosí department in the Bolivian highlands. SUBJECTS: Two hundred and fifty-one households with children aged 6-23 months. RESULTS: In multiple regression models controlling for potential confounding variables, infant and young child feeding (IYCF) practices as measured by an ICFI showed positive associations with child length-for-age Z-score (mean difference of 0·47 in length-for-age Z-score between children in the high ICFI tertile compared with the low tertile), child energy intake (mean difference of 1500 kJ between tertiles) and the micronutrient adequacy of child diets (mean difference of 7·2 % in mean micronutrient density adequacy between tertiles; P < 0·05). Examining determinants of IYCF practices, mother's education, livestock ownership and the crop diversity of farms were positively associated with the ICFI, while amount of agricultural land cultivated was negatively associated with the ICFI. Crop diversity and IYCF practices were more strongly positively correlated among households at high elevations. CONCLUSIONS: Nutrition-sensitive investments in agriculture that aim to diversify subsistence agricultural production could plausibly benefit the adequacy of child diets.

Reducing iron deficiency anemia in Bolivian school children: calcium and iron combined versus iron supplementation alone.

OBJECTIVE: The aim of this study was to determine the effect of combined calcium and iron versus single iron supplementation on iron status in Bolivian schoolchildren. METHODS: Children ages 6 to 10 y old (N = 195), were randomly assigned to receive either 700 mg Ca (as calcium carbonate) plus 30 mg Fe (as ferrous sulfate) (Ca + Fe group) or 30 mg Fe (as ferrous sulfate) (Fe group). The doses were administered daily, from Monday to Friday, between meals at school over 3 mo. Iron status was assessed at baseline and after intervention. Additionally, overall nutritional status was assessed by anthropometry and an estimation of dietary intake. RESULTS: At baseline, the prevalence of anemia in the Ca + Fe group and the Fe group were 15% and 21.5%, respectively. After 3 mo follow-up, the prevalence of iron deficiency anemia dropped significantly (P < 0.001) to 3% in both groups (χ(2) = NS). Iron dietary intake was within recommended levels, but calcium intake only covered 39% of the Recommended Daily Intake. CONCLUSION: Combined calcium and iron supplementation is equally as effective as single iron supplementation in reducing the prevalence of iron deficiency anemia in Bolivian school children.

Using mixed methods to investigate factors influencing reporting of livestock diseases: a case study among smallholders in Bolivia.

Livestock disease surveillance is particularly challenging in resource-scarce settings, where disease events are often unreported. Surveillance performance is determined as much by the quantifiable biological attributes of the disease, as it is by motivations and barriers perceived by livestock keepers for disease reporting. Mixed methods designs, which integrate the collection, analysis and interpretation of qualitative and quantitative data in a single study, are increasingly used across different disciplines. These designs allow for a deeper exploration of the topic under investigation, than can be achieved by either approach alone. In this study a mixed methods design was used in order to gain a greater understanding of the factors that influence reporting of livestock diseases in Bolivia. There is a need to strengthen passive surveillance in this country, among other reasons as part of an eradication programme for Foot and Mouth Disease (FMD). Findings revealed livestock keepers in the study area were extremely unlikely to report the occurrence of livestock health events to the Official Veterinary Services (OVS). Communication outside the local community occurs more often through alternative routes and this is positively correlated with disease awareness. The main barriers to disease reporting identified were a lack of institutional credibility and the conflicting priorities of the OVS and livestock keepers. As for other animal and human diseases across the developing world, passive surveillance of livestock diseases in Bolivia should be enhanced; this is urgent in view of the current FMD eradication programme. Increasing timeliness and smallholders' participation requires a detailed understanding of their likely actions and perceived barriers towards disease reporting. These insights are most likely to be developed through a holistic mixed methods approach of quantitative and qualitative analyses.

Sociocultural dimension of epilepsy: an anthropological study among Guaraní communities in Bolivia--an International League Against Epilepsy/International Bureau for Epilepsy/World Health Organization Global Campaign against Epilepsy regional project.

This study was performed to analyze sociocultural beliefs about epilepsy among Guaraní communities in Bolivia. People with epilepsy, their family members, the general population, and local health care personnel were interviewed about the meaning of and beliefs, feelings, and practices concerning epilepsy. Epilepsy is called mano-mano, a term that means being in a constant passage between life and death. The disease is attributed mainly to a failure to observe a fasting period and to other eating habits. Natural remedies are the most recommended treatments even though half of respondents reported that antiepileptic drugs may be effective. The concept of epilepsy as an embodied disease with natural causes appears to differ from that documented in other traditional societies. People with epilepsy do not represent a threat to the community, which seems to have an attitude aimed at their protection. Moreover, people from these communities appear to favor a combination of biomedical and traditional care systems.

The effects of local medicinal knowledge and hygiene on helminth infections in an Amazonian society.

Social science has long recognized the importance of understanding how interactions between culture and behavior shape disease patterns, especially in resource-poor areas where individuals draw on multiple medical treatments to maintain health. While global health programs aimed at controlling high infection rates of soil-transmitted helminthes among indigenous groups often acknowledge the value of local culture, little research has been able to examine this value. This study investigates the association between parental ethnomedical knowledge, parental biomedical knowledge, and household sanitation behavior and childhood soil-transmitted helminth infections among a group of foragers-farmers in the Bolivian Amazon (Tsimane'). During 2007, a parasitological survey was completed for 329 children (≤ 16 years of age) from 109 households in combination with a comprehensive survey of both of the child's parents to assess biomedical and ethnomedical knowledge and household sanitary environment. Soil-transmitted helminthes were found to be common with 67% of sample positive for hookworm species. Indices that capture a household's relative state of risky and preventive hygienic behavior were significantly associated with risk of hookworm infection. Mother's but not father's ethnomedical knowledge was also negatively associated with a child's probability of being positive for hookworm infection. The effect was stronger for young children and boys. Like many rural populations, Tsimane' actively draw upon multiple medical systems to respond to health challenges. Integration into markets and national societies is likely to affect local medical systems by increasing the use of biomedicine as formal education prioritizes biomedical over ethnomedical systems. This study underscores the value of considering both ethnomedical knowledge systems and household hygiene in public health campaigns to treat and control soil-transmitted helminths. There is no question that providing medication is critical, but this study demonstrates that poverty is not synonymous with either poor hygiene or the lack of valuable ethnomedicinal knowledge.

Assessment and characterization of the diet of an isolated population in the Bolivian Andes.

OBJECTIVES: The goal of this research is to characterize the composition and nutrient adequacy of the diets in the northern region of the Department of Potosí, Bolivia. Communities in this semiarid, mountainous region are isolated and impoverished having the highest rates of child malnutrition and under-five mortality in the Americas. METHODS: A total of 2,222 twenty-four-hour dietary recalls were conducted in 30 communities during May and November 2006 and May and November 2007. Food composition data were compiled from diverse published sources and integrated with the recall data to estimate intakes of energy, protein, fat, carbohydrates, and seven micronutrients. Diets were characterized in terms of food sources, seasonality, and nutrient adequacy. RESULTS: The diet relies heavily on the potato and other tubers (54% of dietary energy) and grains (30% of dietary energy). Although crop production is seasonal, off-season consumption of chuño helps to minimize seasonal fluctuations in dietary energy intake. Despite relative monotony, intakes of iron, vitamin C, most B vitamins, and vitamin A in adults are probably adequate; riboflavin, calcium, and vitamin A intakes in children are low. Nevertheless, extremely low dietary fat intakes (approximately 3-9% of dietary energy from fat) likely prevent adequate absorption of fat-soluble vitamins as well as lead to deficiencies of essential fatty acids. CONCLUSIONS: Dietary inadequacies, especially of fats, may explain much of the poor health observed in northern Potosí. An improved diet may be possible through increasing production and intake of local fat-rich food sources such as small animals.

Iron supplementation in previously anemic Bolivian children normalized hematologic parameters, but not immunologic parameters.

Iron deficiency anemia (IDA) is considered to be the most prevalent micronutrient deficiency in the world. Estimates indicate that 1.2 billion people suffer mild to severe forms of anemia and that up to 46% of schoolchildren in developing countries are affected. In 2003, ENDSA, the national demographic and health survey of Bolivia showed that 60% of children under five and 72% of children under 2 years old were anemic. Micronutrient deficiency has been suggested to impair cell-mediated immunity. In particular, iron, zinc and vitamin A deficiencies have an impact on the immune system. In vitro and in vivo laboratory studies indicate a link between iron deficiency and impaired T-lymphocyte proliferation. The exact effects or mechanisms of iron deficiency on maturation and proliferation of T-lymphocytes in vivo are, however, not yet known. This study investigated the effects of iron on the maturation of T-lymphocytes in anemic but otherwise healthy schoolchildren (no apparent protein-energy deficiency or other morbidity). Anemic children of a poor peri-urban school of Cochabamba city, Bolivia, were given iron treatment for three consecutive months. We chose to look at CD1a+ lymphocytes, which are immature thymocytes. The proportions of CD1a+ lymphocytes in the peripheral circulation measured at baseline and after treatment were compared with a reference group of age-matched non-anemic children controls from the same school. The immunologic parameters, although improved, did not reach the proportions of the control group. Overall, the proportion of circulating immature T-lymphocytes decreased from 18.3% to 9.2% in the treated following iron supplementation in anemic children, compared with 3.4% in non-anemic children.

Relaciones materno-fetales en la infección con T. Cruzi y la implementación de un programa nacional de detección y tratamiento de Chagas congénito en Bolivia / No disponible

La enfermedad de Chagas congénita se produce por la transmisión de Trypanosomacruzi de la madre infectada al feto. Esta infección, característica de la América latina, se extiende a otros continentes debido a la importante migración de mujeres crónicamente infectadas y en edad fértil. La tasa de transmisión materno fetal varía de una región a otra entre el 1 y el 12%.La importante población de mujeres en edad fértil infectadas y el riesgo de transmisión presente en cada embarazo realzan la importancia de este modo de transmisión. La infección materna, cuando no hay infección al feto, parece no influenciar ni el curso del embarazo ni el desarrollo fetal. Sin embargo más del 50% de los recién nacidos con Chagas congénito son totalmente asintomáticos al nacimiento. En los casos donde hay una clínica aparente se puede observar prematuridad, bajo peso al nacer, hepato y esplenomegalia, síndrome de distress respiratorio y anasarca. El diagnostico de la infección congénita puede hacerse al nacimiento mediante la búsqueda de parásitos en la sangre del cordón umbilical o la sangre venosa, utilizando el micrométodo en tubo capilar, complementado, en los casos negativos al nacimiento, con una segunda prueba parasitológica entre 1 y 2 meses de edad, y con las pruebas serológicas después de los seis meses de vida. El tratamiento precoz de la infección congénita con Benznidazol durante 30 días cura prácticamente al 100% de los niños infectados y esta curación se puede confirmar por la negativación de las pruebas serológicas entre 6 meses hasta un año después del tratamiento. Este artículo también presenta resultados del programa de detección y tratamiento de Chagas congénito en tres departamentos endémicos de Bolivia, donde se observa una prevalencia de infección materna superior al 30% con una tasa de transmisión de 2,5% y un cumplimiento del tratamiento en un 83% de los niños infectados (AU)

Congenital Chagas disease is caused by the transmission of Trypanosomacruzi from an infected mother to her foetus. Although characteristically found in Latin America countries, this disease is extending to other continents due to the immigration of chronically infected women of reproductive age. The mother to foetus transmission rate varies between 1 and 12% in different regions. The significant population of infected women of child bearing age and the transmission risk during pregnancy highlight the importance of congenital transmission. In the absence of foetal infection, maternal Chagasdoes not appear to influence pregnancy or the foetal development. However, more than 50% of newborns with congenital Chagas are completely asymptomatic at birth. In cases where clinical disease is present, premature birth, low birth weight, hepatomegaly and splenomegally, respiratory distress syndrome, and anasarca have been observed. Diagnosis of a congenital infection can be done at birth by testing for parasites in the umbilical cord blood or bloodstream and by micromethod. Cases that are negative at birth can be followed-up with a second parasitological test between age 1 and 2months and by serological analysis after age 6 months. Early treatment of infected infants with Benznidazol for 30 days cures almost 100% of cases. Treatment success can be confirmed by negative serological tests between6 month and 1 year after treatment is completed. This article presents the results of a congenital Chagas detection and treatment program in three endemic areas of Bolivia. The observed prevalence of infection was more than 30% with a 2.5% transmission rate. Treatment adherence for infectedinfants was 83% (AU)

Are mosquitoes diverted from repellent-using individuals to non-users? Results of a field study in Bolivia.

Outside sub-Saharan Africa, Anopheline mosquito exophagic and/or crepuscular behaviour patterns imply that insecticide-treated nets may provide incomplete protection from malaria-infective mosquito bites. Supplementary repellent treatment has been recommended in such circumstances, especially where vectors are exophilic and so are not susceptible to residual insecticide spraying. As maintaining complete usage of repellents in a community is unrealistic, the potential negative impact on non-users of repellent usage by 'neighbours' in the same community needs to be addressed in the context of health policy promoting equity. This study quantifies diversion of host-seeking mosquitoes, from repellent wearing to unprotected individuals, 1 m apart under field conditions in Bolivia. Each of the six volunteer-pairs sat >20 m apart from other pairs. Volunteers were allocated di-ethyl toluamide (DEET) or mineral oil in ethanol control. Treatments were rotated, so that during the trial, both pair-members wore repellent on 72 occasions; both pair-members wore control on 72 occasions; and on 36 occasions, one pair-member wore repellent and the other control. Unprotected (control) pair-members received 36.4% [95% confidence interval (CI): 8.1-72.0%] more Anopheles darlingi landings (P = 0.0096) and 20.4% (95% CI: 0.6-44.0%) more mosquito landings (P = 0.044), when their 'partner' wore repellent than when their partner also wore control. A second, smaller Latin-square trial using 30% lemongrass (Cymbopogon citratus) repellent, with control, obtained 26.0% (95% CI: 5.2-51.0%) more mosquito landings when controls sat with repellent-wearers rather than other controls (P = 0.0159). With incomplete community repellent usage, non-users could be put at an increased risk of malaria. The results also have implications for repellent-efficacy assay design, as protection will appear magnified when mosquitoes are given a choice between repellent-users and non-users.

[Ethnographic study of neurological and mental diseases among the Uru-Chipaya peoples of the Andean Altiplano]. / Estudio etnográfico sobre las enfermedades neurológicas y mentales entre los urus-chipayas del altiplano andino.

INTRODUCTION: The Uru-Chipaya people are an ethnic group of about 2,500 people, descendants of primitive Andean cultures. Their isolation (they live at an altitude of 4,000 metres in southern Bolivia), their non-written language (Chipaya-Puquina) and their traditional way of life, clothing and customs, which are similar to those used for thousands of years, make this an unusual culture. The aim of our work was to carry out an ethnographic study of the neurological diseases experienced by these people, the way they conceive such disorders and their therapeutic approaches to them. DEVELOPMENT: An ethnographic field study was conducted in June 2004. A structured interview was held with a yatiri, or Chipaya healer, to allow classification of the neurological or mental diseases. Epilepsy (tukuri) is interpreted as being a consequence of an evil spirit entering through the nose. Treatment consists in drinking an infusion containing dried powdered butterfly (jesko), birds or curupancho. Achamixi (headache) is common and is treated by drinking the yatiri's fermented urine, herb tea made from the chachacoma plant and by blowing, which is done by the yatiri over the patient's head. Fright, the symptoms of which are similar to those of a post-traumatic stress disorder, is treated by a wilancha, that is, the ritual sacrifice of a llama offered to the Pachamama. Sadness, the cultural equivalent to depression, is treated with infusions made from ayrampo, a plant found in the Andean Altiplano. Psychosis (sumsu), which is treated by means of a wilancha, and mental retardation/static encephalopathy (pustkis), which are considered to be a result of a fright suffered by the mother during pregnancy, also exist. No mention was made of the existence of extrapyramidal or vascular pathologies. CONCLUSION: The cultural equivalents of certain neurological pathologies (headache, epilepsy, mental retardation, anxiety and depression) are present in this ancestral culture.

Estudio etnográfico sobre las enfermedades neurológicas y mentales entre los urus-chipayas del altiplano andino / Ethnographic study of neurological and mental diseases among the uru-chipaya peoples of the andean altiplano

Introducción. Los urus-chipayas son un grupo étnico de2.500 personas, descendientes de culturas andinas primitivas. Suaislamiento (viven a 4.000 metros de altitud en el sur de Bolivia),su lengua no escrita (chipaya-puquina), su forma tradicional devida, indumentaria y costumbres, semejante a la llevada a cabodurante milenios, hacen que ésta sea una cultura insólita. El objetivode nuestro trabajo fue realizar un estudio etnográfico sobre lasenfermedades neurológicas de este pueblo, la concepción que tienensobre ellas y sus pautas terapéuticas. Desarrollo. Estudio etnográficode campo realizado en junio de 2004. Se realizó una entrevistaestructurada con un yatiri o curandero chipaya para clasificarlas enfermedades neurológicas y mentales. La epilepsia (tukuri)es interpretada como la consecuencia de la entrada de un malespíritu por la nariz. Su tratamiento consiste en ingerir una infusiónque contiene un polvo seco de mariposa (jesko), aves o curupancho.La achamixi (cefalea) es común, se trata lavando la cabezacon orina fermentada del yatiri, bebiendo la infusión de la plantachachacoma y mediante el acto de soplar que el yatiri realizasobre la cabeza del paciente. El susto, cuyos síntomas semejan untrastorno de estrés postraumático, se trata con la wilancha, sacrificioritual de una llama, dedicada a la Pachamama. La tristeza,equivalente cultural de la depresión, se trata con infusiones deayrampo, una planta altoandina. Existe también la psicosis (sumsu)que se trata con wilancha, y el retraso mental/encefalopatíaestática (pustkis), considerados consecuencia del susto que la madreadquiere en el embarazo. No fuimos informados sobre la existenciade patología extrapiramidal ni vascular. Conclusiones. Losequivalentes culturales de ciertas patologías neurológicas (cefalea,epilepsia, retraso mental, ansiedad y depresión) están presentesen esta cultura ancestral

Introduction. The Uru-Chipaya people are an ethnic group of about 2,500 people, descendants of primitive Andeancultures. Their isolation (they live at an altitude of 4,000 metres in southern Bolivia), their non-written language (Chipaya-Puquina) and their traditional way of life, clothing and customs, which are similar to those used for thousands of years, makethis an unusual culture. The aim of our work was to carry out an ethnographic study of the neurological diseases experienced bythese people, the way they conceive such disorders and their therapeutic approaches to them. Development. An ethnographicfield study was conducted in June 2004. A structured interview was held with a yatiri, or Chipaya healer, to allow classificationof the neurological or mental diseases. Epilepsy (tukuri) is interpreted as being a consequence of an evil spirit entering throughthe nose. Treatment consists in drinking an infusion containing dried powdered butterfly (jesko), birds or curupancho. Achamixi(headache) is common and is treated by drinking the yatiri’s fermented urine, herb tea made from the chachacoma plant and byblowing, which is done by the yatiri over the patient’s head. Fright, the symptoms of which are similar to those of a posttraumaticstress disorder, is treated by a wilancha, that is, the ritual sacrifice of a llama offered to the Pachamama. Sadness, thecultural equivalent to depression, is treated with infusions made from ayrampo, a plant found in the Andean Altiplano. Psychosis(sumsu), which is treated by means of a wilancha, and mental retardation/static encephalopathy (pustkis), which are consideredto be a result of a fright suffered by the mother during pregnancy, also exist. No mention was made of the existence of extrapyramidalor vascular pathologies. Conclusion. The cultural equivalents of certain neurological pathologies (headache, epilepsy,mental retardation, anxiety and depression) are present in this ancestral culture

Impact of a community-based comprehensive primary healthcare programme on infant and child mortality in Bolivia.

Community-based comprehensive primary healthcare programmes are a widely-promoted strategy for improving child survival in less-developed countries, but limited documentation exists concerning their effectiveness in actually reducing child mortality. This study examined the impact of a community-based comprehensive primary healthcare programme on child survival in Bolivia. Mortality rates from two intervention areas where Andean Rural Health Care (ARHC) had been conducting child-survival activities for 5-9 years were compared with those from two geographically-adjacent comparison areas that lacked such activities and that were virtually identical to the intervention areas in socioeconomic characteristics. Vital events were registered at the time of regular visit to all homes. In the comparison areas, limited services were available which reached only a small percentage of the population, while in the intervention areas, prenatal care, immunizations, growth monitoring, nutrition rehabilitation, and acute curative services were readily available to the entire population. In 1992-1993, the annual rates of mortality of children, aged less than five years, were 205.5 per 1,000 and 98.5 per 1,000 in the comparison and intervention areas respectively. The absolute difference in mortality of 107.0 deaths per 1,000 (95% confidence interval [CI], 72.7-141.3 per 1,000) represented 52.1% (95% CI, 35.2-68.8%) lower mortality of children aged less than five years in the intervention areas compared to the control communities. These results suggest that the provision of community-based, integrated health services can significantly improve child survival in poor countries. Better-designed and larger field trials of community-based comprehensive primary healthcare programmes in multiple regions of the world are needed to provide a stronger scientific basis for developing this approach further in developing countries.

Definition and prevalence of anemia in Bolivian women of childbearing age living at high altitudes: the effect of iron-folate supplementation.

This paper discusses the effect that high altitudes have on iron metabolism and summarizes the results of an iron-folate supplementation trial. The two main objectives of the trial were to determine hemoglobin cut-off values for the diagnosis of anemia in Bolivian women of childbearing age living at high altitudes, and to estimate the prevalence of anemia in this population. The study showed that nutritional anemia is an important public health problem in such populations and that many methods of assessing it lead to an underestimation of prevalence. The cut-off values defined through this study, one of the few iron supplementation trials conducted at high altitudes, confirm the need to establish revised hemoglobin values for the diagnosis of anemia in populations living at high altitudes.

Reduction of maternal and perinatal mortality in rural and peri-urban settings: what works?

The purpose of this article is two-fold: (i) to lay out conceptual frameworks for programming in the fields of maternal and neonatal health for the reduction of maternal and peri/neonatal mortality; (ii) to describe selected MotherCare demonstration projects in the first 5 years between 1989 and 1993 in Bolivia, Guatemala, Indonesia and Nigeria. In Inquisivi, Bolivia, Save the Children/Bolivia, worked with 50 women's groups in remote rural villages in the Andean mountains. Through a participatory research process, the 'autodiagnosis', actions identified by women's groups included among others: provision of family planning through a local non-governmental organization (NGO), training of community birth attendants, income generating projects. In Quetzaltenango, Guatemala, access was improved through training of traditional birth attendants (TBAs) in timely recognition and referral of pregnancy/delivery/neonatal complications, while quality of care in health facilities was improved through modifying health professionals' attitude towards TBAs and clients, and implementation of management protocols. In Indonesia, the University of Padjadjaran addressed issues of referral and emergency obstetric care in the West-Java subdistrict of Tanjunsari. Birthing homes with radios were established in ten of the 27 villages in the district, where trained nurse/midwives provided maternity care on a regular basis. In Nigeria professional midwives were trained in interpersonal communication and lifesaving obstetric skills, while referral hospitals were refurbished and equipped. While reduction in maternal mortality after such a short implementation period is difficult to demonstrate, all projects showed improvements in referral and in reduction in perinatal mortality.

PIP: This article presents an analysis of baseline data from four Mothercare projects that provided community-based maternal and child health services in rural Inquisivi, Bolivia; rural Quetzaltenango, Guatemala; rural Tanjungsari in West Java, Indonesia; and Bauchi state, Nigeria. Each project relied on different interventions. All women faced economic, psychological, sociocultural, technical, and administrative barriers in accessing services. The Safe Motherhood Initiative found that people's medical decisions were often based on nonmedical reasons and cultural appropriateness, and that the medical community needs to recognize their competitors in alternative health systems. Maternal and child survival are dependent upon recognition of the problem, decision making about care, access to care, and quality of care. A well-functioning program includes policy formulation, training, IEC, management and supervision, logistics and supplies, and research, monitoring, and evaluation. Study surveys were conducted during the early 1990s. In Bolivia, findings indicate that perinatal mortality declined during 1990-93 to 38/1000 births and fewer mothers died due to pregnancy or childbirth. Family planning use increased from 0 to 27%. The Bolivian project worked to strengthen women's groups. Findings from the Guatemalan project indicate that referrals from traditional birth attendants (TBAs) increased in both the implementation and the comparison areas, but significantly more so in the implementation area. Perinatal mortality among referred women decreased in both areas (from 22.2% to 11.8% in the intervention area). Indonesian results indicate that referrals to birthing centers by TBAs increased from 19% to 62%. Maternal mortality was halved; perinatal mortality declined to 35.8/1000. In Nigeria, maternal mortality declined among all causes.

Epidemiology of coca derivatives use in the Andean region: a tale of five countries.

The countries of the Andean Region (Bolivia, Colombia, Ecuador, Peru, and Venezuela) have recently reported findings from drug use surveys. An integrated comparison of their results and the results from other countries is presented. A total of 24,108 people were surveyed. Lifetime prevalence of cocaine or coca paste use was between 0.8 and 3.0%. The highest prevalence of coca paste or cocaine use was found among individuals who were middle-age, middle-class, males, people who finished high school, those who had high income, and urban dwellers. The most frequent age of first use was 15 to 24 years. The study shows that coca and derivatives use is a public health problem that is affecting a productive segment of the population of this region.