This booklet describes Embassy La Paz. s health care program. It offers medical information on selected topics, describes ways to avoid illness, and outlines how and where to get help when needed.

Most people worry about the affect high altitude will have on them and their family members as well as on the diseases they may encounter in Bolivia. Altitude affects most people in one way or another and there are many diseases one can worry about: tuberculosis, dengue fever, malaria, typhoid, giardia, AIDS and cholera, to name a few. The Health Book discusses these diseases, but more importantly, tells you how to prevent them. Please pay special attention to the advice given on how to prevent disease. And have a healthy tour in Bolivia. We will help you in any way we can!

1. During working hours call the Health Unit at 43-0221 or Ext. 2660 or 2664. In the event of a life-threatening emergency, go directly to Clinica del Sur (Hernando Siles, 3539/Calle 7, Obrajes) and call the medical staff from there. Depending on the type of emergency, go to the hospital by personal vehicle or taxi, call the Roving Patrol (43-3145), or call an Auxilio Médico Ambulance (012-68502). If an ambulance is needed, contact the Health Unit or the duty nurse for assistance.

2. During non-working hours, contact the duty nurse on cellular phone # 012-24861. If you cannot reach the duty nurse, please call Post 1 (432540) for assistance. In the event of a life-threatening emergency, please see the above recommendation.

    

3. In Cochabamba, call Dr.Morgenstern, cell number 017-20234. If directed, or Dr. Morgenstern is unavailable, go to the emergency room of Centro Médico Boliviano Belga, Calle Antezana #0455. Depending on the type of emergency, go to the hospital by private vehicle or taxi, call the Roving Patrol (485757) or call the MEDICAR Emergency Ambulance Service (221592.) Please call the La Paz duty nurse at 012-24861 so we can be aware of the situation and assist, if necessary.

    

4. In Santa Cruz, go directly to emergency room of Clínica Angel Foianini, Av. Irala #468 and call Embassy nurse Catherine Blumhorst (cell #013-61289) and/or Dr. Foianini (cell #016-27647) from there. Depending on the type of emergency, go to the hospital by private vehicle or taxi, call the Roving Patrol (423369), or call the Clínica Foianini Ambulance Service (362211.)

Do not completely rely on the local ambulance services. It is often quicker to transport the patient by private vehicle or in a taxi. You may also contact the Marine Security Guard to dispatch a vehicle or roving patrol to transport the patient. In an emergency, ask for help from a friend or neighbor. Remember, if you are driving, you will not be able to immediately assist someone in distress. If you suspect a back or neck injury, call an ambulance. The victim's head and neck must be immobilized before he is transported. In La Paz, if an ambulance is needed, contact the Health Unit or the duty nurse so we can make sure the ambulance will have the necessary equipment on board.

Basic principles of first aid should be kept in mind in the event of any injury:

• Protect yourself from injury while rescuing the victim. Wear gloves or keep a clean cloth or plastic between your hands and the victim's blood or other body fluids. Alternatively, help the victim use his own hands to apply pressure to a wound.
• If the victim is not breathing, call for help, open his airway and begin CPR.
• Apply a sterile bandage or clean cloth to a wound and then apply pressure to stop the bleeding. Elevate the injured part, if possible, to a level higher than the victim's heart. Application of an ice pack might also be helpful to decrease the bleeding. Do NOT wash a wound if bleeding is a problem. Take or send the victim to the emergency room.
• If a fracture is suspected, the injured part should be immobilized. Immobilize the joint above and the joint below the injury with a splint and/or a sling.
• If the cut or wound is not deep and bleeding is not a problem, wash the wound with soap and plenty of water, dry and cover with a bandage.
• If the victim has a minor burn (red skin with or without blisters and blanches with pressure), cool the burn by immersing it in cold water or gently running cold water on it for 10 minutes. Pat the area dry and cover the burn with a dry sterile dressing or clean cloth. Ice can be applied over the dressing to relieve pain but do not apply ice directly to the burnt skin. Seek medical attention if the burn is deep (white or charred skin), is extensive, or involves the eyes, face, hands or genitals. Do NOT apply butter, raw meat, oils or sprays to a burn.
• To stop a nosebleed, use your thumb and forefinger to apply steady external pressure to both nostrils (pinch the nostrils together) for at least ten minutes. An ice pack over the nose may be helpful.

Medevacs are authorized by M/MED in Washington following recommendation by the Regional Medical Officer (RMO) or the FSHP. Medevacs are recommended when adequate medical or dental evaluation/treatment is not available at post and can not be delayed until R&R or home leave without reasonable expectation of worsening of the condition. Medevacs are coordinated by the Health Unit.

All American U.S. Government employees and authorized dependents covered under the State Department's medical program who hold a valid medical clearance are eligible for medevac to the nearest suitable medical/dental facility. This usually means Miami. Patients may elect to travel to other points within the U.S. and pay the difference. Per diem and transportation costs to the nearest suitable facility are covered by the parent agency, as are costs of hospitalization. However, patients receiving care under this program who are hospitalized must file a claim with their health insurance carriers, and any proceeds from inpatient related charges must be remitted to the Embassy's Budget and Fiscal Office. Patients must have medical insurance to be eligible for their agency. s additional coverage. All outpatient medical and dental costs not related to hospitalization are not covered by the Department's medical program and are the responsibility of the patient. All people not covered under the State Department's medical program who use the Health Unit must have some type of medevac insurance. For a medical evacuation, the Health Unit contacts the RMO in Lima, or M/MED for authorization. Medical evacuation to CONUS is strongly urged for all obstetrical deliveries.

Medevac in conjunction with personal travel, R&R, EVT, or other post-authorized TDY travel can be authorized only for medical treatment or a hospitalization that lasts longer than three days. Per diem, however, is never paid for the period a patient is hospitalized. If you believe this situation has arisen while in the U.S., please call MED (202) 663-1662 to request medevac approval.

The following things must be completed or taken along for medevac travel:

• Medical Evacuation Travel Orders
• Authorization for medical services (FS 569) if medevac. d to a site in South America
• Valid Passport and re-entry visa
• All pertinent medical records/x-ray films
• Valid immunization record
• Medical insurance information
• Airline tickets
• Sufficient funds and credit cards
• Supervisor informed of travel plans and dates
• Informational sheets of requirements for newborn babies and benefits (if applicable)
• Copies of all telegrams related to your travel
• Notarized statement from employee (if patient is a dependent) for travel advances.

Everyone medevac. d to CONUS must be aware that their medical clearance is voided while on medevac and must be reestablished by MED before return to post. Please request a copy of your medical records to return with you to post.

Injuries associated with drinking and driving may not fall under the State Department. s medical treatment program since they involve misconduct. You might find yourself paying for an expensive medical evacuation and hospitalization. Do not drink and drive!

The employee is responsible for all costs related to outpatient doctor and specialty (e.g. physical therapy) visits, whether they are in conjunction with a medical evacuation or not. Charges for laboratory tests, x-rays, etc. that arise from the outpatient visits are also the employee. s responsibility. They should submit medical claims to their insurance carrier to receive the allowable reimbursement. TriCare participants are the exception to this rule. TriCare members must call their TriCare representative to request approval for coverage before receiving any non-emergency medical or dental care. Representatives will NOT accept requests from the Health Unit staff. Physicians who have signed an agreement with TriCare send their charges directly to the insurance company. TriCare participants do not have a co-pay. Please see the Appendix for a list of TriCare-participating physicians.

MED will pay the usual and customary expenses for hospitalization and related outpatient care for illnesses, injuries or conditions incurred overseas. HOWEVER, employees are required to file medical claims with their medical insurance and amounts received in settlement of the claims are to be forwarded to their agency collection office. MED serves only as the secondary payer and liability is limited to the residual after the employee. s own health insurance has paid. Please note that the U.S. Government will not cover expenses that are not covered by insurance (i.e., it will not pay the co-pay for procedures or benefits, such as a private duty nurse, if it is not a benefit provided by your insurance policy.)

The Health Unit in La Paz maintains a list of potential blood donors registered by blood type, for use when emergency blood transfusions are required. Blood donations are strictly voluntary and potential donors are screened for medical conditions that would preclude them from being acceptable donors. In addition, before any volunteer blood is used, it is re-tested for blood type, HIV and Hepatitis antibodies. If you have not been asked to fill out a walking blood bank form and are willing to be a donor, please contact the Health Unit.

Emergency visitation travel (EVT) can be authorized when a parent, child, or sibling has died or when a parent or child is in a life-threatening, critical condition. EVT may be authorized for a member of the Foreign Service when posted abroad or for an eligible dependent . located abroad.. EVT is limited to one round trip for each serious illness or injury of each immediate family member.

Although the Health Unit may be able to answer general medical questions, it is the responsibility of the post. s Human Resources office to contact M/MED for EVT authorization in the case of a life-threatening medical condition. In the even of the death of a parent, sibling, or child Post authorizes the travel. Consult 3 FAM 699.5 for limitations on EVT.

Effective June 20, 2000, federal employees may use a total of up to 12 administrative workweeks (480 hours) of sick leave, each leave, to care for a family member with a "serious" health condition. Effective January 15, 2001, the EVT benefit is extended to permit State Department employees and eligible spouses who are serving overseas to visit a parent who has suffered a breakdown in health requiring reassessment of the parent's living situation (Incapacitated Parent EVT). An employee or eligible spouse is limited to two Incapacitated Parent EVT trips per lifetime (each) and is required to self-certify that proposed travel meets the regulation standards. The post submits the certification to the Office of Employee Relations, which approves or denies travel and provides fiscal data to fund the travel. For Incapacitated Parent EVT only, an employee may designate a spouse to travel in his or her place.

The Health Unit is located on the fourth floor of the Chancery, 2780 Arce Ave. Currently, it is staffed by a Foreign Service Health Practitioner (FSHP), two full time Registered Nurses (RNs), a Health Unit Administrator and a Receptionist. The staff provides health consultation, immunizations, health education and treatment of various illnesses and minor injuries. If specialized or more intensive care is needed, the staff will assist in locating the appropriate specialist, help with admission to the hospital or conduct a medevac to CONUS as necessary.

There is a nurse on call for emergencies 24 hours a day, 7 days a week. The nurse on call always carries cellular phone number 012-24861. Please be certain that before you call the medical on call cellular phone number, the problem is a true emergency, not something that can wait until regular office hours. If you cannot reach the on call nurse on the cellular phone, call Post 1 for further assistance.

Routine visits are for such things as arrival briefings, well-child exams, prenatal exams, clearance exams, and immunizations. Appointments are required for routine visits. Please call ext. 2664 or 2660 to schedule a time convenient for you.

Urgent visits are for such things as sore throats, injuries, headaches, urinary tract infections, and moderately severe vomiting or diarrhea. Health Unit nurses see walk-ins with urgent problems on Monday through Friday, from 9:00 am to 12:00 noon. Because others may be waiting to be seen, please limit your visit to your immediate concern. An appointment can be made for a later time to address your non-urgent concerns.

Medical emergencies are those situations where life is threatened or time is of the essence. Examples include such problems as severe pain, difficulty breathing, chest pain, uncontrolled bleeding, and unconsciousness. People with life threatening emergencies should be taken immediately to the nearest recommended hospital and call the medical staff from there. Non life threatening emergencies (e.g., minor cuts, asthma attacks, severe headaches) are seen as quickly as possible at the Health Unit and on a priority basis. During regular hours, should the occasion arise, call or come to the Health Unit. After hours call the nurse on call for instructions.

The Health Unit operates during the same hours as the Embassy. The Health Unit staff has administrative hours on Wednesday afternoon, so only urgent appointments are made for that time.

Monday to Friday

Mornings 9:00-12:00 Walk-ins (Sick Call) with Nurses

Appointments for HU Briefings

Appointments with FSHP

Afternoons 2:00-5:00 Immunization appointments

(except Wednesdays) Appointments with FSHP

Call the Health Unit at 43-0251 or Ext. 2664 or 2660 for an appointment. The Health Unit nurses see walk-ins each working weekday morning from 9:00 am to 12:00 (no appointment is necessary but expect to wait approximately 30 minutes to be seen.) Immunization appointments are available Monday, Tuesday, Thursday, and Friday afternoons from 2:00 pm to 5:00 pm. The FSHP can be seen only by appointment on Monday through Friday.

The Health Unit does not have a laboratory but can perform rapid tests for pregnancy, blood sugar, strep throat, and urinalysis. All other samples are sent to a competent outside lab for analysis. Unless tests performed at outside laboratories are for a clearance physical exam, the bill is the patient. s responsibility. Certain blood tests can be sent to MED. s laboratory at no expense to the patient. If a test is sent to an "outside" U.S. laboratory, a check must be included with the sample.

Physical exams are done for routine health care or when required for pre-departure/medical clearance purposes. A medical clearance is valid for two years or until the end of your tour, whichever is longer. We regret that the State Department does not provide clearance examinations, at this time, for military personnel, institutional contractors, U.S. Corp of Engineers, or IAGS personnel. Everyone who is a participant in the medical program, who will reside overseas, needs a valid medical clearance. If you are returning to the U.S., you do not need a medical clearance. If you are transferring to another overseas post or returning to post after home leave, you have two alternatives for updating your medical clearance. You may obtain a medical clearance through:

1. The traditional history and physical examination (DS-1843 or DS-1622)

• Performed at post by the FSHP, or
• Performed at the exam clinic in the Department of State. s Office of Medical Services, or
• Performed at a private facility in the U.S. at your home leave address or other location outside a fifty-mile radius of Washington, DC

Or, you may obtain a medical clearance through the completion of:

2. The Medical Clearance Update Form

• May be obtained from the Health Unit, Office of Medical Services or in your bid packet.
• After completion, should be taken to the Health Unit for review with the FSHP. The Health Unit will forward it to MED/Clearances for clearance action.

The Medical Clearance Update form may be sent to the Office of Medical Services early in the bidding process (when or before the bid list is submitted) to expedite your medical clearance. On the form, the employee and eligible family members indicate any medical events that have occurred since the last medical clearance was issued. The form is then submitted to the FSHP. Present holders of a Class 1 Clearance may have their new Class 1 Clearance issued overseas by the FSHP after the completed form is reviewed and the individual is determined to be world-wide available. In rendering a Class 1 Medical Clearance decision, the FSHP may obtain any or all of the laboratory studies and tests routinely requested during the standard clearance examination. A fund site will be requested from MED/EX for these routine clearance exam expenses.

Persons holding a Class 2 (limited) medical clearance may use either of the above methods to update their clearance. If they elect to use the Medical Clearance Update form, pertinent medical reports/comments summarizing their current health status and outlining the recommendations for necessary follow-up care for the next year must be included. The clearance cannot be given at post by the FSHP, but must be sent to MED/Clearances for the clearance action. When preparing to bid, those who have a Class 2 clearance and those who have developed a medical condition which could affect their worldwide availability should inform their Career Officers. The Career Officer will work with the Office of Medical Services to ensure that an appropriate assignment is obtained. Medical approval for an onward assignment depends on the nature of the medical condition and the health care capabilities of the proposed post.

If you would like to have your clearance examination done at the Exam Clinic in the Department of State, the Health Unit must send a cable requesting an appointment about 90 days before your preferred appointment dates. Please call the Health Unit once you know the dates that you will be available for your exam and ask us to send a cable.

All individuals preparing to begin long-term language training must have an updated medical clearance. When you are assigned to language training, update your medical clearance immediately after being officially notified of the assignment.

A mammogram is required for medical clearance of all female employees or dependents 50 years old and older. Screening mammograms may be recommended as part of the clearance examinations for women 40 years or older and paid for at government expense. Of course, any younger woman with abnormal findings or complaints at the time of the examination may have an evaluation at government expense.

Screening flexible fiberoptic sigmoidoscopies (FFS) are offered with every other clearance exam to men and women fifty years of age or over. However, the FFS is required rather than optional with each clearance exam for those who have first-degree relatives with colon-rectal cancer; a personal history of endometrial, ovarian, or breast cancer; or a previous history of inflammatory bowel disease, adenomatous polyps, or colon-rectal cancer; and fecal occult blood.

The Health Unit in Santa Cruz is located in the Consulate. It is staffed by part-time (10 hours/week) Registered Nurse, Catherine Blumhorst. Cathy sees patients by appointment in the Health Unit weekdays from 8:30 to 10:30 am. Walk-ins are seen if time permits. The Health Unit has a small pharmacy and a small supply of immunizations. It does not have a laboratory. All lab tests must be done at outside laboratories. If a medical emergency occurs after office hours, please cal

l Cathy on her cellular phone (# 013-61289) for advice or instructions.

The Health Unit has limited supplies of medications that can be dispensed by the FSHP or the nurses. According to Department of State guidelines, the Health Unit cannot supply patients with long-term and over-the-counter medicines. Each family should arrange to get a supply of long term and over the counter medicines that are used frequently from the U.S.

Prescriptions can be sent to your insurance company. s pharmacy. See information on your insurance company below:

Special Agents Mutual Benefit Association (SAMBA)
Merck-Medco Rx Service
P.O. Box 67006
Harrisburg, Pennsylvania 17106
1-800-283-3478

Alternatively, try one of the following pharmacies that are familiar with State Department procedures:

a) Columbia Plaza
516 23rd Street, N.W.
Washington, D.C. 20007
Fax: (202) 452-7820; Phone: (202) 331-5800
Regular but not class II narcotic prescriptions may be faxed.

b) Morgan Pharmacy
3001 P. Street, N.W.
Washington, D.C. 20007
Fax: (202) 337-4102; Phone: (202) 337-4100

Regular but not class II narcotic prescriptions may be faxed. Morgan Pharmacy requests the original prescription be mailed to them. Include a note stating the prescription was previously filled via fax and the original is being sent for their records. Otherwise, you may receive a double order.

 

c) CVS
2125 E. Street. N.W.
Washington, D.C. 20037
No fax service; phone number: (202) 338-6337

Columbia, Morgan and CVS will include bills with the medications. Pay these bills promptly using a check drawn on a U.S. bank account. Or you may pay by credit card. Medications, as well as eyeglasses, can be sent to you in the State Department's air pouch. Packages should be clearly labeled with your pouch address and the statement:

MEDICAL SUPPLIES
URGENTLY NEEDED

Many drugs and medical supplies can be purchased locally. Choose medications from international companies, if at all possible, because they have an international reputation to uphold. Shop from reputable pharmacies staffed with a pharmacist, not just a clerk. They are more likely to use reputable distributors and have better drug turnover and advanced expiration dates. As a general . rule of thumb,. avoid purchasing medications manufactured by La Far, Delta, and any Brazilian manufacturer. After purchasing a medication at a local pharmacy, you may wish to bring it to the Health Unit so we can verify that it is, in fact, an equivalent of the medication you wished to buy.

Cough/Cold Actifedrin (tablets, elixir) Actifed

Actilab Jarabe (elixir) Actifed Elixir

Flavicold (also drops) Theraflu

Flavicold Plus Theraflu Cough

Benadryl DM-E Robitussin DM

Fever/Pain Aspirina (Bayer) Aspirin

Ascriptin AD Ascriptin/Bufferin

Doloflam (also p/ninos) Ibuprofen/Motrin

Bladex (Elixir) Pediaprofen

Paracetamol (LabChile) Tylenol Elixir

Naproxeno 550-100 Aleve/Naprosyn

Naprosyn Aleve/Naprosyn Instestinal Maalox Maalox

Mylanta II Mylanta II

Kaopectate Kaopectate

Ranitidina Zantac

Skin Neosporin Neosporin

Caladryl Caladryl

Hidrocortisona 1% Pomada Cortaid Max. Strength

Benzac AC 2,5%, 5%, 10% Clearasil, Oxy5/10

Tinaderm Cream, Powder, Soln Tinactin

Clotrimazol 1% Crema Lotrimen AF

~ approximate equivalent

There are numerous physicians in La Paz; many of them had some trained in the United States. If you have a problem that the Health Unit is unable to treat, you will be referred to one of these physicians. You may also visit these physicians or facilities on your own, if you wish, without a referral. Please see Appendix A for a list of referral physicians.

The Post Medical Advisor is Dr. Raul Pinto. He is an internist/endocrinologist. Dr. Pinto did his residency at Sinai Hospital of Baltimore and his endocrine fellowship at Montefiore Hospital (Pittsburgh) and The Joselin Clinic (Boston.) Dr. Pinto had a private practice in endocrinology for 12 years in McAllen, Texas. He is U.S. board certified in internal medicine and endocrinology. He returned to Bolivia in 1996 and has been our Post Medical Advisor since then. His office is at Avenida Arce 2342. His office number is 44-2058, cellular phone is 012-98110, and home number is 740059.

Dr. Juan Enrique Wantig is our Pediatric Post Medical Advisor. His pediatric residency was at Texas Tech University and Kapiolani Medical Center (Honolulu) and his fellowship in pediatric ambulatory care at the Kapiolani Medical Center. He opened a private practice in Honolulu for one year before returning to Bolivia in 1998. Dr. Wantig. s office is located in San Miguel on Av. Montenegro #E2. His office number is 79-6802, cellular number is 012-96550, and home number is 79-3111.

Dr. Koziner is our OB/Gyn Post Medical Advisor. Dr. Koziner completed his OB/Gyn residency at the University Clinic of Berlin (Germany) and the St. Elizabeth Hospital in Recklinghauser (Germany.) He worked at the hospital in Germany as an OB/Gyn for nine years before returning to Bolivia. He has been in private practice in La Paz for 17 years. He has been our Post Medical Advisor for three years. Dr. Koziner has two offices, but the most convenient is located in Calacoto on Calle 21 # 8514 in the Basaure Building, Office 1D. His office number is 79-7287 and his cell phone is 015-20111.

Dr. Ricardo Morgenstern is our primary consultant in Cochabamba. Dr. Morgenstern completed his residency in gastroenterology at the University of Edinburgh (England). He returned to Bolivia in 1990 to set up a practice in Cochabamba. Dr. Morgenstern. s office is located on 777 Baptista. His office number is 29-30-31 and his cellular number is 017-20234.

Dr. Jorge Foianini is our primary consultant in Santa Cruz and has been since 1988. He is an American citizen, American-trained general surgeon. He did his residency in general surgery at The Brooklyn Cumberland Medical Center (Brooklyn) and at the William Beaumont Army Medical Center (El Paso). Dr. Foianini is board certified by the American Board of Surgery. He is the Medical Director and Chief of Surgery of Clínica Angel Foianini. His office is located on Av. Irala 468. His office number is 36-6005 and his cellular number is 016-27647.

Unlike physician care, which is near or at U.S. standards, hospital care is below our standards. Nursing care is available, but the level of training is poor. The number of available staff is small and the comforts of U.S. hospitals may be missing. That said, local hospitals are capable of dealing with most emergencies. See the appendix for health facility address and phone numbers.

Clínica del Sur has been owned by a group of physicians since it opened in 1989. We recommend using this clinic/hospital for all emergencies. The hospital has modern equipment and is viewed as being the best trauma facility in La Paz. It has a small 24-hour emergency room staffed by a general physician. Specialists can be quickly called to the emergency room if needed. If you experience a minor emergency and it is at all possible, call the duty nurse before leaving home so she can call a specialist to meet you at the emergency room. The hospital has 30 beds, 14 of which are in private rooms. It has four operating rooms, an intensive care unit, a coronary care unit, a neonatal intensive care unit, CT Scan, x-ray, laboratory, blood bank, physical therapy unit, endoscopy/bronchoscopy labs, stress testing EKG, and ultrasound.

Clínica Cemes is located a block from the Embassy. It is owned by a group of physicians and has been in service since 1984. It is a small facility with minimal emergency services so is not recommended for major emergencies. We use the hospital for obstetrics, gynecology, general pediatrics and for minor surgeries. Clínica Cemes also offers a laboratory, lithotripsy (for kidney stones), laser eye surgery, ultrasound, a small intensive care unit, a labor room, and a neonatal intensive care unit.

This 60-bed hospital is owned by a group of physicians. The hospital has a well-equipped emergency room, intensive care unit, operating room suite, laboratory, x-ray, CT scan, blood bank, delivery rooms/nursery, pediatric unit, and cardiac unit. The emergency room is staffed 24 hours a day by emergency room specialists. Three operating rooms are available adjacent to the emergency room. The cardiac unit, which has the capability to perform angioplasty, ateriography, angiography, and cardiopulmonary bypass, serves as a medical referral site for all Bolivia for serious heart conditions. The hospital. s usefulness is limited only by the quality of physicians and nurses. Notify Dr. Morgenstern immediately when anyone is taken to the hospital for emergency care or admission.

This 35-bed hospital has a well-equipped emergency room, operating room, intensive care unit, neonatal intensive care unit, laboratory, x-ray, CT scan, and a cardiac catheterization lab. The emergency room is staffed 24 hours a day by a surgeon and a pediatrician, each specialized in emergency care. It has three operating rooms and one delivery room. Private inpatient rooms are available with couches so family members can remain with the patients. The laboratory located in the clinic is being evaluated after several individuals have complained about the accuracy of its results. Notify Dr. Foianini of any hospital admission.

If you visit a physician or health facility, you are responsible for payment of any medical bills, either for the doctor or for any tests. These bills may be submitted to your insurance company for reimbursement. If possible, please pay the medical bill at the time of service. If you are unable to pay your bill at that time, most clinics and referral physicians are willing to send bills to the Health Unit for collection.

Up-to-date immunizations are vital to prevent disease, especially when living overseas. Below are the current recommendations for adults and children in La Paz. Have all immunizations recorded in your yellow WHO cards.

Yellow Fever: Required every 10 years. Vaccination should be avoided by pregnant women and those with severe allergy to eggs.

Cholera: No longer recommended, but a cholera stamp in your yellow card may be necessary for travel to some countries.

Rabies: Recommend pre-exposure immunization for individuals with an increased risk of being bitten by a rabid animal. Immunization consists of a series of 3 shots. Currently, no boosters are recommended unless an exposure event has occurred.

Typhoid: Either a) initial shot and a booster every 2 years or b) 4 oral capsules repeated every 5 years. Because both vaccines are only 70% effective, those vaccinated should still follow proper precautions when preparing food and water.

Hepatitis A: One shot and a booster in six to twelve months. Hepatitis A is a viral infection transmitted by person-to-person contact, or by ingestion of contaminated food or water, particularly raw shellfish.

Hepatitis B: Series of 3 shots. No boosters. Hepatitis B is a viral infection transmitted by blood, contaminated needles and other instruments, and sex.

Tetanus/Diphtheria: Booster every 10 years, or at time of contaminated wound if no booster received within 5 years.

Polio: One booster per lifetime for adults previously immunized with complete series.

Tuberculosis Skin Test: Recommended every year.

Rabies: At any age, same as adults.

Typhoid: Give at age 2years. Oral form is not given to children under 6 years old.

Measles: One dose if between 6-11 months old.

Yellow Fever: At 12 months of age.

MMR: First dose at 12-15 months of age. Repeat at 4-6 years.

Hepatitis A: For children between 2-18 years, 2 doses are given 6-12 months apart.

TB Skin Test: Start at 12-15 months old, at time of MMR-1, and repeat every year.

FLUORIDE SUPPLEMENTATION

Aguas de Ilimani, the water company in La Paz, reports that the local water contains barely detectable levels of fluoride, an element which helps strengthen dental enamel and prevent tooth decay. For this reason, the Health Unit suggests that, while posted in La Paz, children between the ages of 6 months and 16 years should receive daily fluoride supplementation. The Health Unit has fluoride drops and chewable tablets available for your family. In order to provide additional benefit to erupted teeth, your child should chew the tablet and swish it in his/her mouth before swallowing. For children who are unable or unwilling to chew a tablet, you can give the drops or fluorinate the water by dissolving one fluoride tablet in the prescribed amount of potable water. This drinking water can be used to prepare formula, milk, and juice. Children should not receive both the chewable tablet and the fluorinated water!!! Fluoride can permanently stain teeth if too much is taken. Fluoride doses are as follows:

MEDICAL RISKS IN BOLIVIA

Tuberculosis is quite common in most of the Developing World and is endemic in Bolivia. In most cases, you must have prolonged personal contact with an infected person before you can become infected, but not always. Furthermore, people may be quite infectious and appear perfectly healthy. As a result of this, most cases of tuberculosis found in our post population come from household help who do not appear to be sick. A person with tuberculosis may have a persistent cough, unexplained fever, night sweats, weight loss, or other signs of a persistent infection.

Fortunately, most cases of tuberculosis in our American population are caught at a very early stage. This is possible because of the annual "TB skin test". By checking each person's skin test reaction every year, we can be sure that we will catch new cases before they actually pose any real risk to patients and their families.

To prevent tuberculosis, make sure that your household help (especially those working closely with small children) has a physical examination that includes a TB skin test or a chest x-ray. They should have a chest x-ray if they develop any symptoms suggestive of tuberculosis. You must pay for these tests, but it is important to make sure that your household help are healthy and do not present a risk to you of your family. Discharge any household help who have been diagnosed as having active tuberculosis from your service until they have been determined to be no longer infectious. The individual can return to work once his/her sputum culture no longer shows infection.

Cysticercosis is caused by infections with the larval stage of Taenia solium, a tapeworm. It occurs worldwide, particularly wherever pork is eaten raw or undercooked and where sanitary conditions permit pigs to have access to human feces. Infection occurs when people ingest raw or undercooked infected pork (. measly pork. ) or foods or water contaminated with eggs. Cysticerci have been found on lettuce, strawberries, and cabbage that had been irrigated with contaminated water. When eggs are swallowed by people, they hatch in the small intestine and the larvae migrate to the tissues under the skin, muscles, and vital organs of the body where they form cysts (cysticerci). Consequences can be especially grave when the larvae localize in the eye, brain, or heart. Some people will experience seizures, paralysis, severe headaches, or psychiatric disturbances as a result of the cysticerci localizing in their brains. Cysticerci in the eye can cause visual clouding or blindness. Cysticerci in the muscles may cause local inflammation, leading to calcified nodules.

Hepatitis is an infection or inflammation of the liver. There are many causes but the most common cause is viral infection. Viral hepatitis is a contagious disease that is spread from one person to another. There are currently five distinct forms of viral hepatitis: A, B, C, D, and E. Symptoms can be similar for all types. They include loss of appetite, dark urine, light clay colored stools, jaundice and fatigue. When you have hepatitis, the liver is not able to function properly. This allows toxic products to accumulate in the body, adding to the illness. Also, hepatitis adversely affects the liver's ability to rid the body of medicines. If you continue to take medicines on a regular schedule, but the liver is unable to degrade them, they can build up in the body -- exceeding the true recommended dosage. Some medications can be harmful when the recommended dosage is exceeded. It is, therefore, important to be careful what medicines you take if you have hepatitis. In some cases a person will become a chronic carrier, able to spread the disease to others for many years.

Hepatitis A: Also known as "infectious hepatitis". This form is commonly spread by the ingestion of food or water that has been contaminated by unclean hands or fruit/vegetables that have been grown using human fertilizer (night soil).

Hepatitis B: Commonly known as "serum hepatitis". This infection is spread by the direct transfer of body fluids from an infected person to a non-immune person (for instance, using a needle contaminated with blood). Hepatitis B can increase the susceptibility to cirrhosis and liver cancer.

Hepatitis C: Previously known as non-A, non-B hepatitis. Up to 50% of cases are the result of intravenous drug use, sometimes in the remote past. Sexual transmission of Hepatitis C is less common. Approximately 95% of people with acute Hepatitis C have no symptoms, but 50-60% progress to chronic hepatitis.

Hepatitis D: Hepatitis D occurs only in conjunction with Hepatitis B. It is transmitted sexually and by sharing needles (i.e., intravenous drug users).

Hepatitis E: Hepatitis E virus can cause acute but not chronic hepatitis. Like Hepatitis A, E is spread by the fecal-oral route (contaminated food).

General measures:

1. Drink distilled water or boil drinking water for three minutes (rolling boil).

2. Wash all fruits/vegetables carefully before soaking in disinfection solution.

3. Wash hands before preparing food and eating. Make sure all household help do the same.

4. Avoid local injections, including intravenous solutions, and especially blood products.

5. If it is necessary to receive injections at some clinic other than the Health Unit, be sure that sterile disposable needles and syringes are used. All clinics recommended by the Health Unit use sterile needles. Before receiving a blood transfusion, the donor blood should be tested for hepatitis, Chagas' disease, malaria, and AIDS. The Health Unit will always assist with obtaining blood donors from the Mission community in La Paz. Only receive a blood transfusion in a rural hospital if expected to die without it before reaching a major city.

6. Keep immunizations current. Hepatitis C, D, and E (previously called non-A/non-B) have no vaccine available at this time.

Rabies is endemic in Bolivia. It is acquired from the bite of a rabid animal. The disease is invariably fatal since there is no treatment. The most important step toward prevention, is making sure that all our pets are properly immunized. All pet dogs and cats should be vaccinated annually, beginning at 3 months of age. Keeping our children away from stray animals is obviously important, but this is not always possible. We recommend that everyone at post receive the three-shot pre-exposure vaccination series.

If bitten by an animal, the most important first aid you can do is wash the bite with SOAP and water for ten minutes as soon as possible. Call the Health Unit after you have washed the wound for further advice. In most instances, this is enough first aid to kill the rabies virus in the wound. If the animal is unvaccinated or unlikely to have been vaccinated, it should be caught and held in a confined area for 10 days of observation. Do not kill the animal. A post-exposure rabies vaccination series should be started immediately if the animal might be rabid, has not been vaccinated, or cannot be observed for 10 days. If post-exposure vaccination is necessary, those who received the pre-exposure series should be given two doses of the rabies vaccine, one immediately (day 0) and the other on day 3. Those who haven. t received the pre-exposure series should receive the rabies immune globulin (half into the wound and the rest intramuscularly) and the rabies vaccine on the first day of treatment and days 3, 7, 14, and 28. Those living in La Paz can receive the vaccinations at the Health Unit. Those living in Cochabamba can get the vaccine at the Clinica Belga and those in Santa Cruz can be vaccinated at the Clinica Foianinni.

The Office of Medical Services in the State Department has strongly advocated rabies immunization for young children who live overseas. Children's poor judgment about playing with stray animals and their fear about reporting any bites or scratches from these animals put them at risk. Adults who must often work with animals and joggers are considered to be at a much higher risk and these people should also be immunized with a "pre-exposure" vaccination series. Because of the vast number of stray animals and unvaccinated pets in Bolivia, we consider everyone posted here to be at high risk for rabies and encourage everyone to receive the pre-exposure vaccination series. The pre-exposure immunization series offers significant but incomplete protection. It is still necessary to receive the post-exposure treatment as described above.

Approximately 25% of people experience an unpleasant period of acclimatization after they arrive in La Paz. This usually persists for a few days, until the body adjusts to the altitude. Symptoms of adjustment may include headache, nausea, vomiting, and insomnia. These symptoms occur equally in males and females but may occur more frequently in children and teenagers. There seems to be a genetic predisposition to slow adjustment to altitude but we cannot tell who will have the problem. However, those who have had previous difficulties are likely to have similar problems each time they go to altitudes above 8-10,000 feet. Those with pre-existing medical problems and/or respiratory infections such as colds, bronchitis or pneumonia should delay travel until fully recovered. Pregnant women should consider delaying travel to altitude until after delivery or ascending gradually to altitude. Individuals with hypertension, diabetes, angina pectoris, heart disease, anemia, hemaglobinophathies (e.g., sickle cell disease and trait), significant obesity, asthma, or emphysema should see their physician for clearance to come to altitude.

All adults and children over the age of five coming to La Paz should take the drug Diamox (acetazolamide) 125 milligrams (or 1/2 tablet of 250 mg) by mouth twice a day, beginning on the day of the flight and continuing for three (3) days after arrival until improved. Diamox significantly reduces, and in most cases prevents, the symptoms of high altitude sickness. This drug must be obtained by prescription from a physician or the Department of State Clinic. Diamox contains sulfa and cannot be taken by those allergic to sulfa. Common side effects include numbness and tingling of hands and feet and frequent urination. These symptoms are minor, short-lived and will disappear once you stop taking the medication. Visitors who do not have access to the Health Unit can purchase Diamox at a local pharmacy under the name "Acetazolamida". Only the 250mg strength is available (take 1/2 tablet twice daily).

If you have a respiratory illness, delay your arrival until improved. Avoid drinking alcoholic and caffeinated beverages on the airplane. Instead drink plenty of water, juices and other non-alcoholic and non-caffeinated beverages.

The sensations that you experience on arrival, such as increased respiration, a pounding heart, and some lightheadedness are all normal adaptive processes. Much of what you feel during the first days at altitude is from dehydration. You need considerably more fluids (in the form of water, juices, broths, Gatorade, herbal teas, Kool-aide, and like drinks.) Avoid alcoholic drinks for the first week and then be cautious and moderate. Limit carbonated drinks or allow them to go flat before drinking them.

Starches (pasta, potatoes, bread and rice) should make up a large part of your diet. Your adjusting body will best tolerate frequent, small, and light meals. Non-chocolate candy, taken frequently on arrival at altitude, can be helpful. Avoid eating heavy, high fat meals, especially at night. A body adjusting to altitude cannot digest fat very well.

Limit your activities for the first few days. Avoid doing a lot of walking or lifting. Children and young athletic adults are more likely to develop serious complications, so guard them against over-activity until they are well adapted. On the other hand, the frequently given advice to lie down during the initial hours in the altitude can actually increase the headache if overdone.

Take two tablets of Tylenol, with a full glass of water, every four hours for headache. Camomille (manzanilla) and coca tea may help alleviate nausea. Avoid drugs such as alcohol, sleeping pills, and narcotics that can interfere with your breathing. Avoid . soroche. remedies such as . Coramine. and . Micoren.. These can increase adjustment symptoms. Also avoid smoking for one week. Bolivians have a local saying regarding altitude adjustment: . eat lightly, walk slowly, and sleep alone..

Please call the Health Unit or the duty nurse as soon as possible if you experience severe fatigue, a severe headache, shortness of breath (especially if it continues at rest), vomiting, onset of a cough, lack of coordination, and confusion.

If you have chronic or recurrent insomnia, take one tablet of Diamox 125mg at bedtime for the entire period you are having difficulty sleeping. People who have taken Diamox every night for their entire tour have not had any ill effects. Few people, however, need to take Diamox after being at altitude for three months. Altitude-related insomnia is probably caused by sleep apnea, a condition in which the person stops breathing for prolonged periods of time during their sleep. People who are overweight or who snore are more prone to sleep apnea. Sleeping pills can worsen sleep apnea. Diamox, on the other hand, stimulates your respiratory center to encourage your body to breathe more often.

Altitude-related constipation is caused by dehydration and a fiber-poor diet. Effective treatment for constipation begins and ends with adequate fluid intake. Drink plenty (at least eight full glasses a day) of non-alcoholic, non-caffeinated drinks. Also, an adequate (800 grams/day) intake of fruits and vegetables is needed to produce a normal bowel movement. Raw and cooked fruits and vegetables and cereals (including their skins and bran) will provide the needed fiber. Eight hundred grams of fruits and vegetables is equal to about four pieces of fresh fruit and a salad. Prunes and prune juice have been found to stimulate the intestine and so are extra-beneficial in treating constipation. Drink more fruit juices and eat more peaches, apricots, pears, beans, peas, raisins, cauliflower, broccoli, and spinach. Avoid eating or drinking large amounts of constipating foods such as milk, ice cream, yogurt, cheese, and cooked carrots. If your constipation does not respond to the above treatment, please let us know.

Due to the low environmental air pressure at altitude, intestinal gas expands. You may experience in La Paz what some call . terminal flatulence. even if you did not have problems with intestinal gas at sea level. Although nothing can be done to completely eliminate the problem, a few changes might help. Eat slowly, chew with your mouth closed and avoid gulping food. Allow carbonated (fizzy) drinks to go flat before drinking them. Don. t chew gum. Avoid any of the following foods that you find especially gas-producing: beans, bagels, brussels sprouts, cabbage, carrots, celery, corn, eggplant, leeks, lentils, milk, onions, peas, pimentos, potatoes, radishes, sauerkraut, scallions, shallots, sorbitol (in diet foods), soybeans, turnips, wheat germ, raw apples, apricots, bananas, citrus fruit, prune juice, and raisins.

The dry La Paz air dries everything, including skin and eyes. Using humidifiers in your home may alleviate this problem. If not, you may need to use moisturizers. For dry skin, bathe/shower in warm (not hot) water, using a moisturizing soap such as Dove. Immediately after your bath, apply a lotion or bath oil to your skin. You may need to re-apply lotion to dry or itchy areas several times daily. Use chapstick on your lips to prevent chapped lips. If your eyes become dry and irritated, instill drops of artificial tears several times a day. Bolivians recommend creams with silicone and glycerin for dry hands.

High altitudes provide less screening from the sun's harmful rays so extra caution is necessary. Minimize your sun exposure during the hours of 10 a.m. to 2 p.m. when the sun is the strongest. Wear a hat, long-sleeved shirt and long pants when out in the sun. Apply a sunscreen before every exposure to the sun and re-apply it liberally at least every two hours as long as you stay in the sun. Sunscreens with a minimum SPF (sun protection factor) of 15 are recommended. Don't forget to apply sunscreen on overcast days. The sun's rays are as damaging to your skin on cloudy days as they are on sunny days. Beware of reflective surfaces such as sand, snow, concrete and water. These surfaces reflect more than half of the sun's rays onto your skin. Sitting in the shade does not guarantee protection from sunburn. Wear UV protective sunglasses. UV irradiation has been found to cause early cataracts, particularly in mountainous and seashore populations. Keep young infants out of the sun. Begin using sunscreens on children at six months of age and then allow sun exposure with moderation.

Fascioliasis or . liver rot. , caused by the liver fluke F. hepatica, can be found in all major sheep and cattle-raising areas of the world, including Bolivia. The adult is a large parasite, measuring 20-30 mm in length (2-3 finger widths). It is a parasite of sheep, cattle, deer, and rabbits, as well as other herbivorous mammals (like llamas). After spending some time in its intermediate host, a snail that lives in ponds and sluggish brooks, it changes to its cyst form on grasses, watercress, bark, or soil. People and animals become infected with F. hepatica after eating the infected plants or drinking infected water. After hatching in the intestine of its new host, the larvae pass through the intestinal wall, eventually reaching the liver, and migrate to the bile ducts, eating liver tissue en route. They mature in 12 weeks.

The symptoms caused by fascioliasis depend on the intensity of infection and the duration of disease. A single fluke can cause a lot of liver damage as it migrates through the liver to the bile ducts. It may also block the bile duct. Severe headache, chills, fever, an itchy rash (hives), a stabbing mid-chest pain, and right abdominal pain that radiates to the back and shoulders may be the first signs of infection. As the infection progresses, an enlarged, tender liver, jaundice (yellow skin), digestive disturbances, diarrhea, and anemia develop. Diagnosis is based on finding the eggs in stools, although the eggs may not appear in the stools until three to four months after being infected.

Fascioliasis is treated with bithionol. This medication is hard on the heart so anyone taking it should rest during treatment. Fascioliasis can easily be prevented by not eating raw, untreated vegetables such as watercress in endemic areas such as Bolivia and by thoroughly cooking liver before eating it.

American trypanosomiasis is a disease produced by infection with Trypanosoma cruzi. It is transmitted to humans (and other vertebrates) by an infected reduviid bug. These bugs like to live in houses made of mud and wattle with cracked walls and thatched roofs, which provide ideal cover during the day. At night, they prey on their human hosts and domestic animals. The bugs defecate (poop) during feeding, releasing feces infected with T. cruzi. Human infection occurs when the bug feces contaminate the eyes, mouth, skin wounds (including the bite wound, after being scratched.) T. cruzi can also be transmitted by blood transfusion, from mother to baby, and organ transplantation.

Chagas. Disease may have two phases, though the acute phase is usually only seen in children. Many infected people have no symptoms at all. The child with acute disease will have fever, feel tired, and have enlarged lymph nodes, liver, and spleen. Inflammation at the site of infection (called a chagoma) may last up to eight weeks. Swelling of an eyelid (Romaña. s sign) occurs in a small percentage of cases. Life-threatening signs include inflammation and swelling of the heart and of the lining of the brain and spinal cord.

Although most infected people will never develop any symptoms, 10-30% of those infected will develop irreversible signs of chronic disease later in life. Irreversible heart damage with heart dilatation and rhythm and conduction abnormalities may occur. Intestinal damage may lead to an enlarged esophagus and colon. Treatment is available for Chagas. Disease, but is most effective during the acute phase.

Chagas. Disease is a wide-spread illness in Bolivia, probably affecting about 40% of the population. The insect that transmits the disease is found in most locations below 3,500 meters and predominantly in rural areas. We are at a lower risk than the general population for getting the disease because our houses are constructed in a manner that is not hospitable to the reduviid bugs. Our risk of getting the disease may come from emergency blood transfusions. However, the blood banks we use in La Paz, Cochabamba, and Santa Cruz all screen donors for T. cruzi.

Cutaneous Leishmaniasis is an ulcerative skin or mucosal (mouth, nose, and throat) disease caused by the protozoa Leishmania. The protozoa is transmitted to humans and rodents by sand flies. The disease is common among farming communities in newly cleared forest areas and in road construction and mining workers. In Bolivia, it is most prevalent in the tropical and subtropical zones. Sand flies are about one-third the size of mosquitoes, are noiseless fliers, and rare bites may go unnoticed.

A few weeks to several months after infection, an itchy red bump appears at the site of the sand fly bite. It may become scaly or gradually enlarge, developing a firm raised border with an ulcer in the center. It is usually painless. The natural progression of the lesion depends on which Leishmania species is the infecting agent. Some resolve after six months while others take several years. Some species tend to spread through the body to the ears, nose, and mouth.

Leishmaniasis is diagnosed when the parasite is seen in a smear or a biopsy of the lesion. A positive skin test will also lead to treatment. Medication is available to treat the infection, but plastic surgery may be necessary if there has been significant tissue destruction.

To prevent leishmaniasis, avoid outdoor activities when the sand flies are most active (dusk to dawn.) Wear protective clothing, covering as much of the body as possible, and use a DEET insect repellent. Bed nets (at least 18 holes/inch) and door and window screens are also helpful.

Malaria is a tropical disease that is increasing in significance in Bolivia. It does not currently present a significant risk to the expatriates living in the large cities of Bolivia but does present a risk to those traveling to or living in areas close to the Brazilian border. It is a dangerous parasitic disease that can be fatal if you do not take appropriate steps to protect yourself.

There are 4 different species of malaria parasites. The most deadly species is Plasmodium falciparum. It can be found in the Pando, Beni, and Santa Cruz Departments. The city of Santa Cruz, however, is relatively free of malaria. The P. falciparum found in Bolivia is fairly resistant to chloroquine and Fansidar (used commonly to treat malaria.) Plasmodium vivax, a less deadly species, is found in all Departments in Bolivia but Oruro but is still sensitive to chloroquine. P. ovale and P. malariae are rarely seen here.

Malaria is normally spread by the bite of an infected anopheles mosquito. These insects are nocturnal feeders, so the most dangerous time for infection is between dusk and dawn. In adults, malaria symptoms can resemble influenza. Fever, especially with shaking chills, is common, as are headache and muscle soreness. Symptoms in infants can be vague and include decreased appetite, difficulty with feeding, and lethargy. If you have been in a high-risk area for malaria and you have a fever, especially if accompanied by headache and chills, please contact the Health Unit or a local physician so that a malaria smear can be done.

It is imperative that a malaria smear be taken before you begin treatment for malaria. If you are traveling away into isolated areas, check with the Health Unit on how to do your own malaria testing, which should be done before any treatment is begun. We will supply you with some anti-malaria drugs and guidelines for treatment in case you develop malaria.

If you develop malaria while here in Bolivia, it can be treated with a variety of drugs such as Halfan/doxycycline, Fansidar/chloroquine combinations or rarely, quinine followed by doxycycline. A new medication, artemether, is showing promise as a safe and effective treatment for malaria. There are, however, problems with production and it is not FDA-approved. If you are allergic to the above listed drugs, you should advise the Health Unit so that we can devise a treatment plan with the RMO before you contract malaria.

Some physicians treat malaria presumptively (i.e. without laboratory evidence of a positive slide) with intravenous Quinine or Quinimax. Please avoid this if at all possible! It is frequently unnecessary and can be dangerous, in some cases, when the patient has been taking mefloquine for prophylaxis. Quinine should be given only when a definite diagnosis has been made and the malaria seems to be resistant to other drugs, and even then under very close supervision.

There are two ways to prevent malaria. Avoid mosquito bites and take your malaria prophylaxis. If you are not bitten by an infected mosquito, you will not become infected. If you are bitten and have taken preventive medication, you are much less likely to become infected.

Prevention consists of protective measures that limit exposure to biting mosquitoes. Although it sounds simplistic, prevention can be highly effective. The less the number of mosquito bites, the less the risk of infection with malaria. Preventive measures include:

1. Avoid outdoor activities at night when possible. The mosquitoes which transmit malaria are primarily active (biting/feeding) from dusk to dawn.
2. Remain in well-screened areas at night. Where screening is inadequate, sleep under a "tucked in" mosquito net.
3. When outdoors at night, wear clothes that cover most of the body, such as long-sleeve shirts and pants.
4. Apply insect repellent containing 33% deet (N, N-diethyl-M-toluamide) to the skin. The 3M deet lotion is considered best and is stocked in the Health Unit. It can provide protection for up to 12 hours and will not wear off because of perspiration or humidity.
5. Spray Permanone (permethrin) tick/insect repellent over clothing and socks. This should provide adequate protection for one day or a bit longer. We have this in the Health Unit. It can also be sprayed on mosquito netting and will enhance the netting's effectiveness.
6. Use a pyrethrum-containing flying insect spray (Raid, Baygon, and others) in living and sleeping areas, particularly under beds and behind curtains.

Prevention of malaria is also accomplished by taking preventive medication. The Department of State currently recommends mefloquine as the drug of first choice for malaria prevention. Although mefloquine has rarely been associated with serious reactions (e.g. hallucinations, convulsions), it is generally well tolerated when used for prophylaxis. If minor side effects such as gastrointestinal disturbances, insomnia, or dizziness occur, they usually clear within a short period of time. The dose of mefloquine is as follows:

Mefloquine 250mg. tablets, take once a week on the same day:
Under 20 lbs 1/8 tablet
20 to 42 lbs 1/4 tablet
43 to 66 lbs 1/2 tablet
67 to 99 lbs 3/4 tablet
Over 100 lbs 1 tablet

Mefloquine should not be taken by individuals with known mefloquine sensitivity and by those with a history of epilepsy or significant psychiatric disorder. In 1996, MED removed the restriction for mefloquine use in pregnant women, children under 30 pounds, and individuals taking beta-blockers, as long as they have no underlying heart rhythm abnormalities.

An alternative drug for malaria prevention is Doxycycline. This is recommended by the Department of State for those who are intolerant of mefloquine or for whom mefloquine is contraindicated. The adult dose is one capsule (100 mgs) daily. Doxycycline can not be used by pregnant women, children under 8 years, or by those allergic to tetracycline medications.

For those unable to use either mefloquine or doxycycline, the Department of State recommends weekly chloroquine and daily proguanil (Paludrine) for malaria prevention. Both may be taken safely by children and pregnant women. The doses are as follows:

Chloroquine 250mg. tablets, take once a week on the same day:
Up to 31 lbs 1/4 tablet
32 to 65 lbs 1/2 tablet
66 to 100 lbs 1 tablet
Over 100 lbs 2 tablets

Proguanil(Paludrine) 100mg tablets, take every day:
Up to 21 lbs 1/4 tablet
22 to 30 lbs 1/2 tablet
31 to 65 lbs 1 tablet
66 to 100 lbs 1 1/2 tablets
Over 100 lbs 2 tablets

At the end of tour, if you have been living in an area that is high-risk for malaria, it is necessary to take the preventive medications above for an additional 4 weeks and also take another medication, Primaquine, for 14 days. Two of the four types of malaria, vivax and ovale, are suppressed while taking mefloquine, doxycycline, or chloroquine and Paludrine, but are not eradicated from the body. Although not common, these two types of malaria can exist as dormant cysts in the liver and mature months or possibly years later causing relapses. Primaquine is given to prevent this and rid the body of any residual malaria parasites.

Before starting primaquine, you must know the results of your G6PD blood test. G6PD, an enzyme in the blood, is either normal or low, and remains the same for life. The test need only be done once and is usually done as part of the initial-hire physical exam.

If you do not know your G6PD status, the test can be done here in Bolivia. If you have left post and do not know your status and cannot find it in your medical records, have the test done in the U.S. either at the M/MED lab, if you are eligible for service there, or else through a private physician.

If your G6PD is low, do not take Primaquine, as serious anemia problems can occur. Should you come down with fever of uncertain cause or symptoms of malaria, alert your doctor to the possibility of this illness. These types of malaria (vivax and ovale) can be readily treated.

If your G6PD is normal, finish the final four weeks of mefloquine, doxycycline, or chloroquine and Paludrine. At the beginning of the third week start Primaquine (issued in 15 mg tablets) daily for 14 days according to the following schedule:

Up to 31 lbs 1/4 tab
32 to 65 lbs 1/2 tab
66 to 100 lbs 3/4 tab
Over 100 lbs 1 tab

A few people have side effects of Primaquine, including: mild to moderate abdominal cramps, nausea, vomiting and dark urine. If these occur, stop taking the drug and see your local physician. The actual risk of recurrent malaria after you stop this drug is small and a lag of a few days before you see the physician is not critical.

The Health Unit can supply you with Primaquine before you leave, or you can get it at most U.S. drugstores with a prescription. The pills come only in one size. They will be difficult to cut. Even so, it is strongly recommended that you and your children comply with this portion of your malaria treatment.

We are occasionally asked about the effect of malaria prophylaxis on pregnancy and if pregnant women should take it. The answer is yes! The effect of malaria on pregnancy is much more serious with possible disastrous consequences to the fetus. In addition, many treatments for malaria are extremely dangerous during pregnancy and make treatment of the infection difficult.

Chloroquine and Paludrine are considered safe and pregnant women are advised to take both drugs if they reside in a malaria region. Mefloquine has also been approved for use in pregnancy. Pregnant women who cannot tolerate chloroquine, Paludrine, and mefloquine or who have no desire to take medications to prevent malaria during pregnancy should leave the malaria region. Doxycycline cannot be taken during pregnancy.

Dengue Fever (. breakbone fever. ) is a viral illness transmitted by Aedes aegypti mosquitoes. In the 1980s, Ae. aegypti mosquitoes invaded Brazil, Ecuador, Paraguay, and Bolivia causing large epidemics& and the mosquitoes stayed. Outbreaks continue to occur in Bolivia, primarily along its tropic border with Brazil. The Ae. aegypti mosquito feed during the day (whereas the mosquito causing malaria feeds at night), primarily the two hours after sunrise and before sunset. Five to eight days after a bite from an infected mosquito, the victim will suddenly develop a fever, chills, headache, eye pain, and an ache in his lower back. He may develop a generalized red flushlike rash that will go away in 24 to 48 hours. Bone and muscle pains will increase in severity (therefore the name . breakbone fever. ). On the second to fourth day, he will develop a loss of appetite, nausea, vomiting, respiratory symptoms, exhaustion, increased skin sensitivity, and altered taste. Throughout the course of the illness, he may have nosebleeds, gum bleeding, and small petechial hemorrhages in the skin. These symptoms are associated with the virus and are generally not worrisome. On the third to fifth day, his fever will resolve and he will develop a rash on his chest and back, which soon spreads to his face, arms, and legs. He may experience several weeks of weakness, depression, and heart symptoms (e.g., palpitations and a slow heart rate) during his recovery. Treatment for classic dengue fever is symptomatic and consists of Tylenol for pain and fever, bed rest, and plenty of fluids.

People with impaired immune systems or a previous exposure to dengue fever, however, may develop severe bleeding problems when they should be recovering, around the second to fifth day. This is called dengue hemorrhagic fever. These individuals become very restless, develop severe weakness, and may go into shock (cold and clammy hands and feet, sweating, bluish lips, and collapse.) Up to 50% of people with dengue hemorrhagic fever will die if not hospitalized and treated promptly with intravenous fluids. That number drops to 5% with proper treatment. Please notify the Health Unit right away if any of these symptoms develop.

To prevent dengue fever, drain all pools of water near your home and work which might serve as mosquito breeding grounds. Cover open bathroom drains. Use mosquito repellents, mosquito nets, and window screens to discourage the mosquitoes from biting you.

Yellow fever is also a viral infection transmitted by the bite of an Aedes aegypti or haemagogus moquito. Yellow fever occurs in tropical areas and is endemic in eastern Bolivia. It can cause very mild or unnoticeable symptoms, a self-limited influenza, or a severe illness that can lead to death within days. The interval between the bite of an infected mosquito and the onset of symptoms is generally three to six days. A typical infection is characterized by a sudden onset of fever, chills, headache, backache, generalized muscle pain, nausea, and vomiting. The person. s skin becomes yellow (jaundiced) and the color intensifies as the disease progresses. Most infections resolve after five days. Approximately 10-20% of the cases, however, progress to serious bleeding problems after a short remission. These people may experience nose bleeds, have bleeding gums, vomit blood, and have blood in their stools. Death may occur from liver, kidney, and/or heart failure. Up to 50% of patients who present with these symptoms will die regardless of the treatment given.

A safe and effective vaccine has been available for 50 years. Everyone over the age of nine months should receive the vaccine, which provides long-lasting immunity after seven to ten days. Re-immunization every 10 years is recommended for anyone remaining in or traveling to an endemic area.

AIDS is a transmissible, fatal condition that suddenly appeared in the last quarter of the twentieth century in some of the most medically advanced societies in the world. It is called SIDA in Spanish. It is a real problem globally and is becoming a problem in Bolivia. Although AIDS is caused by a virus and is a contagious disease, it is not spread in the same manner as the common cold or chickenpox.

AIDS is spread by intimate sexual contact. This includes contact with body fluids of an infected person. AIDS is also spread by unclean needles and by contaminated blood products.

1. Sexually active homosexual or bisexual men with multiple partners.

2. Heterosexual men and women with multiple partners or one partner who has multiple partners.

3. Present or past IV drug abusers.

4. Those who have received blood transfusions, especially before 1986.

5. Sexual partner of a person with AIDS or a person in the high risk group without AIDS.

Do not have sex except in a long-term monogamous relationship where both partners have tested HIV negative for more than 1 year. If you feel this is unacceptable for you, there are a few things you can do to reduce the risk of contracting AIDS.

1. Wear a condom, start to finish, when you have contact with genital mucosa with or without intercourse.

2. Avoid sexual activities that may cause cuts or tears in the mouth, rectum or vagina.

3. Do not have sex with male or female prostitutes (or those who do).

4. Do not have sex with IV drug abusers (or those who do).

5. Avoid local injections/blood products.

6. Use recommended dentists whenever possible for dental procedures.

If you are a person who feels you may be at risk for AIDS, a blood test can be done through the Health Unit, M/MED or at Lab-Tek. All tests are treated as Medically Confidential! The results of this test, or any other medical information, will not be released to outside medical authorities unless requested by the patient in writing.

Traveler' s diarrhea is defined as three or more unformed stools in 24 hours in a person from an industrialized nation traveling/living for a short period of time in a less developed country. Unlike in the United States, where most diarrheal disease is viral, in developing countries bacterial infection is the cause of diarrhea in at least 80% of cases. Pathogenic Escherichia coli accounts for 40-50% of cases. Other common bacterial causes include Campylobacter jejuni, Shigella, and Salmonella. All these organisms are efficiently spread by the fecal-oral route (hand to mouth.)

Symptoms will develop, usually, within eight to 16 hours. Stool cultures are necessary to identify the pathogen and confirm which antibiotic will be most effective. Any clean container can be used to collect the specimen, but the Health Unit has special specimen cups available. The collected specimen should be taken as soon as possible to the laboratory or to the Health Unit. Once the culture is collected, the Health Unit will treat you presumptively with an antibiotic. Immodium or Peptobismol can also be taken if the diarrhea is not bloody or severe. The most important part of the treatment plan, however, is rehydration. The Health Unit will also treat you with an oral rehydration solution or intravenous fluids if you are severely dehydrated. Please see the section on treatment of diarrhea for more information.

Preventive measures include not drinking tap water, not using ice in beverages (even alcoholic drinks), not eating untreated raw vegetables, not eating fruits that can. t be peeled on the spot and not eating mayonnaise, pastry icing, unpasteurized dairy products, raw fish like ceviche and undercooked shellfish. Hot cooked food, fresh bread, dry foods such as crackers, bottled carbonated beverages, coffee, tea and beer are usually safe, provided such food items are not purchased from street vendors. Remember: . boil it, cook it, peel it or forget it.. Also remember the rule of P. s: food is safe if it is peelable, packaged, purified or piping hot.

Bacillary dysentery (also called shigellosis) is caused by a bacteria that invades the wall of the large intestine and causes inflammation and ulceration of the bowel wall. These open "wounds" in the bowel wall release blood and pus that can be seen in the frequent small stools. Other symptoms include an urgency to empty the bowel, pain when emptying the bowel, high fever, headache and abdominal pain. Symptoms range from mild to very severe. At times the individual may not have any symptoms. Uncomplicated bacillary dysentery is usually a self-limited illness that does not necessarily require any specific treatment, but laboratory tests are necessary any time you notice blood or pus in your stools.

Even very small numbers of bacteria can cause the infection, so it is not uncommon to have a large number of cases from a single dinner or social event. Being careful about food preparation and dishwashing procedures in the home will go a long way toward preventing this potentially serious infection.

Typhoid fever is an acute infection caused by the bacteria Salmonella typhi. S. typhi only infects humans, so all cases of typhoid fever are transmitted, directly or indirectly, from the stool or urine of another infected human. Typhoid is usually transmitted indirectly from contaminated food or water. Food can be contaminated by fertilizers, the water used to wash or prepare it, contact with contaminated human hands, dust, and by flies. At first, the number of organisms on the food or in the water may not be enough to cause disease. The body can fight small amounts of the bacteria. But under optimal conditions, the organisms can multiply in food and milk, forming enough numbers to cause infection.

Typhoid symptoms vary tremendously from person to person. The infection starts as a flu-like illness with fever, chills, headache, sore throat, cough (less common), achy joints, and tiredness. Symptoms progress over the next several days, and temperatures rise into the 104° F degree range, with peaks in the afternoon and evening. Most individuals with typhoid have abdominal pain and either constipation or diarrhea (constipation is more common in adults). Without treatment, the mortality rate can be as high as 30%. Use of antibiotics shortens the length of the illness and reduces the rate of complications. The diagnosis of typhoid is confirmed by finding S. typhi organisms in the stool, blood, or bone marrow. The Widal (blood) test is not a sensitive or a specific test for typhoid, but can be useful.

To prevent typhoid, pay careful attention to the quality of the food you eat and the water you drink, and get immunized. Typhoid vaccines provide reasonable (51-76%) protection in most circumstances but are not very effective against heavily contaminated food or water. S. typhi in water is killed by heating to 135° F, iodination, and chlorination. S. typhi in food and milk is killed at the same temperature, but the food must be heated uniformly for several minutes. Raw fruits and vegetables must be thoroughly washed in iodinated or chlorinated water. The best treatment as always is prevention.

Cholera is an acute infection of the small intestine that is characterized by profuse watery (rice water colored) diarrhea, vomiting, muscular cramps, and dehydration. The disease is spread through contaminated water, seafood and other foods contaminated by the excrement of persons with the infection. Prevention is based on avoiding contaminated foods and water. The cholera vaccine is not effective so is not offered by MED or the Health Unit.

Symptoms of the disease are variable. Generally there is an abrupt onset of painless, copious watery diarrhea that causes rapid and severe dehydration. The dehydration itself is usually the cause of the serious complications of the infection.

Diagnosis is made by finding the causative organism (Vibrio cholera) in the stool. Treatment involves replacing the fluids and salts lost because of the diarrhea. This must be done as quickly as possible. While simple oral rehydration is usually adequate, rehydration with intravenous fluids may be necessary.

Giardia infection is characterized by explosive watery diarrhea. The odor of the stool and the accompanying gas is foul smelling. Other symptoms include abdominal bloating or swelling, nausea, sulfur-like (rotten egg) belching, loss of appetite, headache, and weight loss. It is not uncommon for people to complain of increased symptoms after drinking milk.

The cysts of Giardia lamblia are usually found in contaminated water and on dishes or utensils rinsed with contaminated water. The cysts are killed by boiling water for three minutes and by washing dishes with soap or detergent. Medical treatment is necessary to eliminate Giardia. Although this is not an easy parasite to diagnose by stool examinations, three fresh stool specimens on alternate days will usually uncover the infection.

Amebiasis is an infection of the large intestine cause by Entamoeba histolytica, a one-celled protozoa that can constantly change its shape. Symptoms can range from no symptoms, to mild intermittent diarrhea and constipation, to severe diarrhea. The incubation period for amebic dysentery (severe diarrhea) is about 7 to 21 days. The onset is often sudden. Typical symptoms of acute amebic dysentery include: diarrhea, severe intestinal cramps, chills, fever, exhaustion, nausea, headache and a persistent desire to empty the bowel.

There are two forms of E. histolytica: the motile trophozoite and the cyst. The trophozoite is the parasitic form, the one that causes the symptoms. With diarrhea, the fragile trophozoites pass unchanged in the liquid stool and rapidly die. Without diarrhea, the organism changes to the cyst form before leaving the intestines. The cyst is very hardy and can survive long enough to be reingested. Since the cyst is the infective form and can only be passed through firm stools, people who transmit the infection probably don't know they are infected. These people are called asymptomatic carriers.

Once swallowed, the cysts change to trophozoites in the small intestine. These trophozoites travel to the large intestine to grow and multiply. The ameba then attack the mucous lining of the intestine, causing ulcers. These ulcers may spread and/or become infected with bacteria. They may bleed. Other possible complications include intestinal perforation, amebic appendicitis, and intestinal hemorrhage. E. histolytica can occasionally travel to places outside the intestine, causing liver and lung abscesses. Amebiasis is not a self-limiting condition. There can be serious consequences if it is not properly treated. The Health Unit uses a two-phase treatment for amebiasis. The first medication is used to kill the trophozoites in the intestine and other areas they may have traveled. The second medication is used to kill the cysts in the intestines so a reinfection does not occur.

Ameba are usually transmitted by raw fruits or vegetables fertilized by human feces, by food prepared by asymptomatic carriers, and by contaminated water. To prevent infection with ameba, observe the recommended food and water precautions. Amebic cysts are almost immediately destroyed at boiling temperature. Vegetables and fruits should be properly cleaned and treated with strong concentrations of chlorine or iodine. It is also a good idea to have household help evaluated for possible infection. Local labs will check stools for ova and parasites at a reasonable cost.

Cryptosporidium is a protozoa that can cause a foul-smelling diarrhea. It is transmitted through fecal-contaminated water or food. The incubation period is one to two weeks. People suffering from cryptosporidiosis may experience flu-like symptoms, with abdominal cramps, nausea, vomiting, low-grade fever, loss of appetite, weight loss, and headache. These symptoms usually last between 3 to 12 days, but can go on for as long as 21 days. Cryptosporidium cysts may pass in the stools for up to 50 days. Although cryptosporidiosis can be fatal in individuals with AIDS, it is a self-limiting condition in people with normal immune systems. The most important treatment is to remain well-hydrated. No one antibiotic has been found as the cure for Cryptosporidium. Research seems to indicate that paromomycin (Humatin), a medication used to treat amebiasis, may be useful.

Employees and food handlers who work in the home are a potential source of illness for others. A medical exam prior to employment is wise. This should include a general physical exam, a chest x-ray to screen for tuberculosis, and 3 stool tests to screen for parasites. Yearly exams are advised. Medical exams and the care and treatment of domestic employees are the responsibility of the employer and are not done in the Health Unit. In La Paz, Dr. Hugo Palazzi (Office phone 43-1826) is aware of our recommendations and will do the employee physical examination, lab work and chest x-ray for approximately Bs 320.00. Please call the Health Unit for more information.

If your employees become ill, make sure they receive medical attention. You may wish to go with them to their doctor to understand what is wrong and to help pay for treatment. It is a good idea to provide leave time during episodes of acute illness.

Every worker, even those who have worked for Americans many years, should be given complete instructions about each job. Do not assume that they know what they should do. They will not ask for help because to admit they do not know something is shameful to them. Domestic employees should be carefully instructed in proper personal and household cleanliness, including such procedures as food preparation and handling, and dishwashing. Insist that they wash their hands frequently with soap and water before any food preparation (or each time they enter the kitchen, would be even better) and after toilet use. It may be wise to repeat instructions frequently and to make sure they are understood and correctly carried out. Finally, provide soap and clean towels for the frequent and thorough hand washing necessary in the kitchen.

The worker should change uniforms at least every two days and should have a clean one ready to wear. Nannies should change uniforms daily. Dish towels and hand towels should be changed at least every two days. Dish drying towels should not be used for anything else, nor should they be draped around the neck. Insist that anything that drops on the floor should not be used until it has been washed. Supervise the washing of fruits and vegetables to be eaten raw until you are confident that they will continue to do it properly. They should also be taught to handle food as little as possible, to use ice tongs when putting ice cubes into drinks, and to clean and prepare food as discussed below. Surfaces on which food is to be prepared should be carefully cleaned before each use. Counters may be washed with a Clorox solution to cut down on the bacteria. Cooked food should not remain uncovered. Leftovers should be placed in the refrigerator as soon as possible.

Most domestic workers respect and appreciate good teaching and positive supervision, pleasantly but firmly given. This makes for a much happier and healthier household than does turning everything over to the worker and ignoring what is being done or becoming angry or fussy and critical when work is not done to your satisfaction.

Water quality varies widely throughout Bolivia. Water treatment is in the process of being privatized in the major cities. Some cities have had more success than others at turning water treatment over to competent companies. We continue to recommend that you take precautions with the water. All water used for drinking, brushing teeth, making ice cubes, or for cooking should be either boiled or taken from the distiller. Boiled water should be brought to a rolling boil for three minutes, no matter what the altitude. That should allow sufficient time to destroy bacteria, parasites, cysts, and viruses that may cause infection. An alternative method of disinfecting water is to add two drops of chlorine bleach to each quart or liter of water and waiting 30 minutes. Small quantities of water, for travelers, can be treated with iodine containing tablets (Globuline, Potable Aqua, EDWGT-Coughlans). Filter cloudy water, first, through a cloth such as a handkerchief. Then add 2 tablets of iodine to 1 quart of clear water, replace the container cap lightly, wait 5 minutes and shake well. Then tighten the cap and wait an additional 30 minutes before water is consumed. Inspect the tablets before using. If they are not a grayish blue, significant iodine has been lost. With deterioration the color fades and turns yellow green and the tablets become crumbly.

When in restaurants and hotels, drink only water that is bottled and be sure the bottle is sealed when it is delivered to you. Also, avoid drinks served with ice cubes. Freezing does not kill organisms like giardia, it only makes them angry!

Many diseases and most intestinal problems can be avoided if care is taken with food and drink. Here are some suggestions.

• Fruits and vegetables: Purchase your fruits and vegetables from a supermarket instead of an open-air market. Vegetables and fruits sold at open-air markets have probably been irrigated with highly contaminated water. Supermarkets usually require that their produce suppliers irrigate with clean water. The use of clean water decreases the potential contamination. All fruits and vegetables should be washed thoroughly with detergent and running water. Those that will be cooked or peeled can then be stored in a sealed container until used. Those that will be eaten raw and will not be peeled should be soaked for 15 minutes in a solution of chlorine bleach (or 5% household bleach) in water, (one tablespoon of clorox per gallon of water), rinsed with potable water, and allowed to air dry. A locally manufactured solution, DG6, is used by many Bolivians to treat their produce. DG6 is very effective against bacteria but has never been tested against parasites. Therefore, we cannot recommend its use at this time.

• Meats and seafood: Eating raw or undercooked beef, pork, sausage, and fish can lead to trichinosis, tapeworm, fluke infections, and other diseases. Smoking, salting, pickling, and drying meat and fish will not protect against these problems. To be safe, these products should be well cooked. Freezing meat is effective in killing most organisms but some organisms, like trichinosis, are very hardy and will withstand freezing temperatures for up to 30 days.

• Eggs and dairy products: To help prevent Salmonella poisoning, eggs should be washed in the same manner as vegetables. Eggs with cracked shells should be discarded. Because of the risk of salmonella infection, eggs should be well cooked. Raw eggs should not be used in foods that will not be cooked. Dairy products, unless they are known to be hygienically prepared and properly refrigerated, should be avoided. Milk should be pasteurized.

• Eating out: To help prevent illness after eating out, avoid eating raw vegetables and salads, custards, cream-filled pastries, mayonnaise, potato salads, raw fish such as ceviche and raw shellfish. You should drink only bottled beverages. Reputable restaurants will make lemonade with bottled or boiled water, however.

• Dishwashing: Dishes should be washed in warm soapy water. They should be rinsed in a basin of hot tap water to which a tablespoon of bleach was added. They should then be left to air dry.

Diarrhea is one of the most common problems we encounter in Bolivia. Diarrhea is defined as frequent, watery stools. It can be caused by parasites, viruses or a variety of bacteria. In La Paz, most diarrhea is caused by viral or bacterial infections. Amebiasis is more common at lower altitudes. Most cases of mild diarrhea only require the prevention of dehydration with appropriate fluids, followed by a bland diet for several days. All patients with severe diarrhea (stools every hour), blood and/or mucus in the stools, severe abdominal cramping, or symptoms of dehydration (see below) should be evaluated by the Health Unit.

A variety of organisms can cause infectious diarrhea. Viruses attack the part of the small intestine involved in absorbing water and sugars. The body, therefore, cannot absorb these very well and a watery diarrhea develops. This diarrhea will decrease with fasting. Viruses, typically, are self-limited, causing symptoms for three to eight days. Bacteria cause diarrhea by releasing poisons that bind to the mucous lining of either the large or small intestine and cause inflammation. The inflamed lining then secretes fluid into the intestine, causing diarrhea. This diarrhea does not improve with fasting. Parasites vary in their method of causing diarrhea. Some, like Entamoeba histolytica, invade the intestinal wall, causing ulcers and inflammation. Although not completely understood, it is believed that Giardia causes diarrhea by disrupting absorption.

Although viruses are self-limiting and bacteria and parasites can usually be treated with medications, the most serious treatment concern is usually dehydration. Dehydration occurs when the body's water output exceeds its water intake. Symptoms of dehydration can range from mild thirst to dry lips, absent tears, sunken eyes, decreased urination, exhaustion, listlessness, difficulty thinking, cold arms and legs, grunting, rapid respirations and heart rate, shock, and coma.

The best (and safest) treatment for dehydration is oral rehydration therapy. In the 1960's it was discovered that water is best absorbed from the intestine when it contains a certain amount of salt and sugar. That finding led the World Health Organization to develop and promote the use of the Oral Rehydration Solution (ORS) to treat dehydration. The dry ingredients come in a package and are mixed with water before use. If vomiting poses a problem, ORS can be given every two to five minutes, a teaspoonful at a time. Vomiting will usually stop once rehydration is underway. The Health Unit has packets of ORS.

More recently, cereal-based solutions have been shown to be as effective as glucose-based solutions in the treatment of dehydration. Although no cereal-based solution is available commercially, the solution can be prepared from ingredients available at home. To prepare the solution, mix 1/2 cup of dry, precooked baby rice cereal with two cups of water and 1/4 teaspoon of salt. The resulting mixture should be thick, but pourable and drinkable, and it should not taste salty. Another rehydration solution can be made by mixing 1 liter of water, 2 Tbsp of sugar, ¼ tsp of salt, ¼ tsp of baking soda, and ½ cup of orange juice. Breast fed babies should continue to breast feed. Human milk appears to diminish the duration and severity of diarrhea.

Although "resting the bowel", by taking only clear liquids for a certain period of time, was once recommended, this has now been found to prolong the course of diarrhea. We recommend starting a bland (no fat) diet, especially one containing wheat noodles or other carbohydrate-rich staple food, shortly after the rehydration therapy is started. Since diarrhea can cause a temporary lactose intolerance, cows' milk intake should be limited.

As mentioned, water is best absorbed from the intestine when it contains a certain amount of salt and sugar. Plain water should not be used to treat dehydration. Solutions with a high concentration of sugar or salt (such as cola, 7-up, apple juice, and chicken broth) should also not be used. When these concentrated solutions enter the intestine, water is actually pulled out of the blood stream (worsening the dehydration) to dilute them.

Pepto-Bismol can be used to relieve some of the discomfort and irritation of the bowel that goes along with diarrhea. It has also been shown to reduce the duration of diarrhea. Medications which slow down intestinal movement (i.e., Immodium and Lomotil) or absorbents (i.e., Kaopectate) should be avoided, as they decrease the body's ability to rid itself of the viruses/bacteria causing the problem.

Call the Health Unit if you have more than 10 episodes of diarrhea in one day or more than five episodes a day in an infant under six months of age. Call if it fails to improve in a couple of days; if it is accompanied by fever above 101° F orally, abdominal pain, blood in the stool, or frequent vomiting. We may recommend collecting stool specimens for evaluation. Bacterial diarrhea is very common in Bolivia and the lab results will assist us in your treatment.

A "cure" for the "common cold" continues to elude us. As a viral infection, upper respiratory infections, or "colds" have to run their course. The medicines we give such as antihistamine-decongestants (like Actifed), decongestants (like Sudafed), or expectorants (like Robitussin) do not have any effect on the infection itself. They only treat the symptoms. Symptoms can be relieved with the following remedies:

For all colds:

• Increase your liquid intake. (Warm tea with honey and lemon is a favorite home remedy.)

• Take medications to reduce the fever and aches such as Tylenol or Ibuprofen.

• Take antihistamine-decongestant combinations to reduce the runny or congested nose.

For sore throats:

• Gargle with warm salt water several times daily: 1/4 tsp salt to 1/2 cup water.
• Take throat lozenges.
• Please come to the Health Unit to be tested for . strep throat. if your sore throat is not associated with a cold, it hurts at the back of your mouth when you swallow, and/or the glands right below the angle of your jaw are swollen and painful. Strep throat is very common in La Paz.

For cough:

• If you have a congested cough, take an expectorant such as Robitussin (plain). Increased fluid intake and a humidifier will also help loosen secretions so they can be coughed out.

• If you have a dry cough, a cough suppressant such as Robitussin DM will help decrease the cough. Cough drops and humidifiers will also help soothe the cough reflex.

You should be seen at the Health Unit if your symptoms are severe or last longer than the usual five to seven days duration of a "cold". Severe symptoms include: difficulty breathing, difficulty swallowing, difficulty opening the mouth, joint pains, chest pain, earache, rash, fever over 101° F, blood in saliva or phlegm, lump in the neck, or hoarseness lasting over two weeks.

Being in Bolivia can make fevers frightening because of the fear of the unknown. But fever in Bolivia is not much different than fever in the U.S. Treatment of the fever is no different. It is just as important to look for the cause.

You have a fever if your temperature is over 99.5° F orally, 100.4° F rectally, or 98.6° F under the arm. Mild elevation can be caused by exercise, excessive clothing, a hot bath, or hot weather. Fever is a symptom, not a disease. Fever is the body's normal response to infections and plays a role in fighting them. Most fevers caused by viral illnesses range between 101° F and 104° F and last for 2-3 days. In general, the height of the fever doesn't relate to the seriousness of the illness. How sick you feel or how ill your child looks is what counts. Fever doesn't cause permanent harm until it reaches 107° F. Fortunately, the brain's thermostat keeps untreated fevers below this level.

Because fever helps you fight infection, treatment should only be started with a fever over 100° F (orally) and if you are feeling uncomfortable. Acetaminophen, or Tylenol, is the drug of choice for controlling fever in most conditions. Two hours after given, acetaminophen will reduce the fever 2 to 3° F. It will not bring the temperature down to normal unless the temperature was not very high to begin with. Acetaminophen can be given every 4 to 6 hours, but not more often.

Age and Dosage

mg = milligrams; ml = milliliters; tsp = teaspoon; tabs = tablets

Ibuprofen and acetaminophen are similar in their ability to lower fever, and their safety records are similar. One advantage that ibuprofen has is a longer-lasting effect (6 - 8 hours instead of 4 - 6 hours). Liquid ibuprofen (Motrin) was approved by the U.S. Food and Drug Administration in 1989 for treating fever in children 6 months to 12 years old. Ibuprofen is not recommended for use in children with chickenpox.

The American Academy of Pediatrics has recommended that children (through 21 years of age) not take aspirin if they have chickenpox or influenza (any cold, cough, or sore throat symptoms). This recommendation is based on several studies that have linked aspirin to Reye's syndrome, a severe encephalitis-like illness. A hidden source of aspirin that is commonly overlooked is Pepto-Bismol. Don't give your child Pepto-Bismol if he or she has a fever.

Sponging is not usually necessary to reduce fever. It is used in emergencies such as heatstroke, delirium, a seizure from fever, or any fever over 106° F. It may also be used if the fever is over 104° F, stays high 30 minutes after taking acetaminophen, and your child is uncomfortable. Except in cases of emergencies (listed above), do not sponge your child without giving him acetaminophen or ibuprofen first. Until the medicine has taken effect (by resetting the body's thermostat), sponging will just cause shivering, which is the body's attempt to raise the temperature. Water for sponging should be lukewarm (85 to 90° F). Sponging works much faster than immersion, so seat your child in 2 inches of water and keep wetting the skin surface. If your child shivers, raise the water temperature or wait for the acetaminophen to take effect. Don't add rubbing alcohol to the water; it can cause coma if breathed in.

Drink extra fluid. Sweating during fever causes a loss in body fluids. Wear light clothing because most heat is lost through the skin. If your child feels cold or is shivering put on a light blanket. Once the fever has been controlled, call the Health Unit for an appointment to try to determine the cause of the fever.

In Bolivia, temperatures are measured in Celsius. To convert Fahrenheit to Celsius, subtract 32, multiply by 5 and divide by 9. To convert Celsius to Fahrenheit, multiply by 9, divide by 5 and add 32.

There are two species of poisonous snakes in the sugar or banana plantations and dry hilly regions of Bolivia. The crotalidae species or Pit Vipers (rattle snakes, although some are rattleless) and the Elapidae (coral snakes) are the only poisonous varieties. Wear long pants and boots when hiking.

If a snake bites you, there are several rules you should follow, keeping in mind that in most cases, even if it was a poisonous snake, there is only a 50% chance that any venom was actually injected.

Remember: Anti-venom can be given at any time up to several days later, if it is really necessary. * More deaths result from improper use of anti-venom, than from snake bites themselves.

Injury is responsible for more childhood deaths than all other causes combined. Children are inquisitive, active and, at times, uncoordinated. No environment is completely safe. Many injuries, however, can be avoided if we are aware of the hazards in the areas where children live and play and if we take steps to reduce these hazards. The most important element for your child. s safety is a watchful and attentive adult. Help make your child. s environment as safe as possible.

Traffic accidents are the biggest cause of death in Foreign Service personnel stationed overseas. They are also the #1 preventable cause of death in young children. The best way to prevent injury is to place infants and young children in car safety seats.

• Infant Seats: Babies must ride facing the rear until they weigh at least 18-20 pounds and can sit up by themselves. Convertible seats must face the rear if the infant weighs less than 18-20 pounds or cannot sit up independently. Once the infant weighs more than 18 pounds and can sit up independently, the seat may be turned to face forward. Toddler seats must be properly installed so the seat will not move. There are many models of safety seats. Follow the manufacturer. s directions. Booster seats are recommended for children who have outgrown toddler sized seats or who weigh at least 30 pounds. Do not use a booster seat without properly using the safety devices designed for it.
• Safety Belts: A combination lap/shoulder belt provides better protection than a lap belt alone. The shoulder belt should fit across the shoulder and breastbone, down to the hips. If the shoulder belt crosses the face and neck, it should be tucked behind the child. s back, never hooked under the arm. The back seat is the safest place for a child, especially if the car has air bags.
• Do not drink and drive!

• Bicycle Safety: Head injuries are the most serious bicycle-related injury. The majority of these head injuries can be prevented if all children wear a bicycle helmet approved by Snell Memorial Foundation or American National Standards Institute every time they ride a bicycle.Insist that children wear helmets every time they ride a bicycle. Teach children to obey all traffic laws, including direction of travel, road signs, traffic signals, and use of hand signals when on the road. Require children to wear bright clothing when riding bicycles. Do not allow riding at dusk or after dark.

• Place a list of emergency numbers, including the Poison Control number by the phone.
• Make sure your smoke detectors are working.
• Develop a fire escape plan and practice it with your family.
• If you smoke, never smoke in bed.
• Reduce the temperature of your water heater to 120-130° F.
• Cook on the back burners of stoves when possible and turn pot handles inward. Keep high chairs and stools away from the stove.
• Use placemats instead of tablecloths that can be easily pulled, overturning hot drinks.
• Unplug extension or electric appliance cords from wall sockets after using them. Cover unused electric outlets with safety plugs or outlet covers. Do not overload extension cords.
• Always keep side rails up while the infant is in the crib. The crib slats should be no more than 2 3/8 inches apart. Use bumper pads around the entire crib until the infant begins to stand, then remove then.
• Lower the mattress before the baby can sit alone and place it in its lowest position as soon as the baby can stand. Once the child is 35 inches tall, he should no longer sleep in a crib.
• Keep stairways as clear as possible. Railing supports should be no more than 6 inches apart. Child safety gates installed at the top and bottom of all stairways will help prevent toddlers from dangerous explorations. Gates should be firmly attached and have a flat bar across the top. Do not use the accordion-type gate with wide gaps at the top.
• The American Academy of Pediatrics does not recommend the use of walkers because they have been consistently associated with serious falls.

Childhood poisoning is a common problem in our society. Our homes contain many harmful chemicals used for cleaning and enough medications to be considered miniature drugstores. It is not surprising that curious and exploring children are often victims of poisoning. Children are at special risk when they are hungry, defiant, daring, imitative, or moving faster than their parents. Children are at highest risk between the ages of two and three years.

A poison is any substance (solid, liquid or gas) that impairs health or causes death when introduced into the body or onto the skin surface. Virtually any substance can be poisonous if enough of it is consumed. For example, aspirin is not usually though of as a poison, but overdoses of this drug kill many children each year.

The most frequently-taken poisons are medicines, soaps, detergents, cleaners, perfumes and vitamins. Children like these products because of their brightly colored packages, pleasant odors, sometimes pleasant tastes and attractive, candy-like shapes. Common poisonous household products include medications, cleaning and polishing agents, detergents and bleaches, lye and acids, ammonia, glue, alcohol and liquor, plants, gasoline, oils, fuels, pesticides and fertilizers, paint and paint thinners, moth balls, insect or rat poisons, nail polish and nail polish remover, deodorant and hair spray, eye and facial makeup.

In case of poisoning, the Health Unit must be notified. A Poison Control Center in the U.S. should be called for advice. Poison Control Centers have accurate, up-to-date and immediate information about almost any poisonous or potentially poisonous product. They can also provide immediate first-aid instructions. The center will need to know the poison. s ingredients. Please have the poison. s container/label nearby when you call in case the center asks for more information about the product. The telephone number for the Poison Control Center of Washington, DC is (011-202) 625-3333. The alternative poison control center is in New York City, telephone number (011-212) 340-4494 or (011-212) 764-7667.

Syrup of Ipecac has been used to induce vomiting in poison victims since the 1950s. However, it is no longer recommended for routine use in most poisonings. Clinical studies have demonstrated no benefit from its use. Call the poison control center for advice before giving Ipecac. If it is recommended, it must be given within 60 minutes of the poisoning. Syrup of Ipecac doses are as follows:

• Adolescents and adults: 15-50 mL followed immediately with 240mL (8 oz) of water.
• Children 1-12 years: 15 mL preceded or followed by 120-240 mL (4-8 oz) of water.
• Infants 6 months to 12 months: 5-10 mL preceded or followed by 120-240 mL of water.

"Culture Shock" is a term used to describe the psychological disorientation people experience when they move, for an extended period of time, into a culture markedly different from their own. It is a somewhat inevitable occupational hazard of living overseas, regardless of the number of previous overseas tours. It comes from cumulative experiences of encountering different ways of doing, organizing, perceiving or valuing things. The proverbial cultural "rug is pulled out from under you" when your usual ways of communicating and dealing with people or situations are no longer appropriate in the new culture. This creates a growing sense of insecurity that may lead to feelings of hostility towards the host country and/or a desire for isolation from it.

Symptoms can range from barely noticeable to clinical depression. Although they can vary significantly in severity, symptoms follow predictable stages. In the first stage, you may enjoy seeing the differences. You probably started your tour with a positive mind-set. Everything was new and exciting and you were impressed by the fundamental similarities between all people. Your first reaction may have been "How quaint!" This tourist/honeymoon stage lasts from a week to a month. After settling in a bit, you move on to the second stage. You start to focus more on the differences. Americans tend to focus on standards of cleanliness, attitudes, punctuality, and the value of human life. These differences become more irritating. You may begin to withdraw, feel homesick, and avoid cross-cultural experiences.

During the third stage, you become more distressed. The host culture is now the scapegoat for all your difficulties. Insignificant problems become major catastrophes. Hostility toward the host nationals, irritability, episodes of crying, compulsive eating or drinking, problems with sleep, and difficulty concentrating on work can be experienced during this stage. The fourth stage is a period of adjustment. The major crisis is over. You have learned a little about the culture so it is no longer overwhelming. You become more comfortable in it. Gradually, your sense of humor returns as you realize that the situation isn't hopeless after all. You will begin to find certain things about the host culture that you enjoy and will miss when you leave.

The interesting thing about culture shock is that there are routinely two low points. Even more interesting, they will accommodate themselves to the amount of time you intend to spend in the host country! The longer you stay, the more spread out those low times will be. During a two-year assignment, the first dip often occurs at 4-6 weeks and a second dip at 4-6 months. Although a certain amount of culture shock is inevitable, there are certain steps that can be taken to minimize the impact. The best antidote is to study the country and culture. The more you learn, the less strange the culture becomes. Try to look at your experiences from your hosts' point of view. Identify a host country national with whom you can discuss your experiences. Resist making jokes and comments that are meant to illustrate the stupidity of the "native" and don't hang around the Americans who do. They will only reinforce your unhappiness. By focusing on the positive, you can overcome culture shock.

It is common, for those facing the multiple losses associated with moving to a new post overseas, to experience times of "feeling blue" or "down in the dumps". This is a normal response (as with culture shock). "Feeling blue" becomes abnormal when the symptoms occur almost daily, are severe, and last more than two weeks. These symptoms may be associated with clinical depression.

Depression is a common illness affecting over 6 million Americans annually. It affects people of all ages, but is 2-3 times more common in women than in men. People with depression have difficulty functioning well in their jobs/schools, physically and socially. Besides experiencing less interest and pleasure in activities, depressed people may develop chronic intestinal symptoms, a change in appetite, multiple body aches, chronic headaches, sleep disorders, fatigue, difficulty concentrating, feelings of worthlessness and hopelessness, irritability, palpitations, dizziness, and recurrent thoughts of death or suicide.

Depression is treatable. If you think you may be depressed, contact the Health Unit for an evaluation.

Alcoholism is defined by the American Society of Addiction Medicine as a primary chronic disease influenced by genetic, psychosocial, and environmental factors. The disease is often progressive and fatal.

Alcoholics generally have no trouble staying away from alcohol for varying lengths of time. It is the "staying stopped" that becomes so difficult. Many alcoholics are periodic drinkers who have little difficulty making it through the week without drinking or drinking moderately. The problem is that when they drink on the weekends they lose control.

There are predictable stages of alcoholism. The early stage is an increased physical tolerance for the drug. The individual can increase how much alcohol he takes and still function normally. He may feel proud that he can hold his liquor better than others. But then, slowly, it will take increasing amounts of alcohol to get the same effect. Then a subtle preoccupation with alcohol-related activities begins to emerge. The person develops less interest in social events that do not involve alcohol.

The middle-stage alcoholic starts to show less control over alcohol. He may pre-drink before a party, gulp the first drink, or "fortify" himself with alcohol. He will try to gain control over alcohol by switching to a drink with less alcohol content, by going "on the wagon" for a period of time to prove that he doesn't have a problem, or by making himself rules about when he can drink. The bottom line is this: social drinkers can take it or leave it - they do not need to control or use energy regulating their alcohol consumption. Talking about, thinking about, or trying to "control" alcohol intake is a dangerous red flag.

The final stage of the disease is obvious even to the most casual observer. Signs include morning drinking, frequent loss of control or overdrinking, prolonged binges, job loss, financial dependence, delusional thinking, suicide attempts, and serious withdrawal symptoms.

Early identification and treatment is far more successful than an attempt to combat the disease in the later stages. Alcoholism rarely can be treated without outside help. Since alcoholism is viewed as a medical problem, MED has set up a program to attempt to deal with the illness. The process was set up to ensure the individual's dignity and self-respect. All counseling and medical assistance is given promptly and discreetly. The exact nature of the problem is never revealed to others without the individual's consent. The first step to treatment is to ask for help. Contact the Health Unit or Pepe (015-33320), who can direct you to a local Alcoholics Anonymous group.

The Family Advocacy Program was formed to address issues of child abuse or neglect, as well as abuse of the spouse and other dependent family members. It is meant to facilitate the identification, treatment, and disposition of children who are victimized, and to allow for legal investigation. The Crime Control Act of 1990 specifically mandates that certain professionals in federally operated facilities, such as U.S. Embassies, Consulates, and overseas missions, report cases of actual or suspected child abuse or neglect to a designated law enforcement agency, specifically the Office of Diplomatic Security.

In La Paz, the DCM has been designated as the Family Advocacy Officer (FAO), coordinating the investigation of such cases. Other members of the Family Advocacy Team (FAT) are the RMO, Regional Psychiatrist (RMO/P), FSHP and the Regional Security Officer (RSO).

AMID (Use mostly to transport patients) 2221949, 2226767

(T) Clinica del Sur 2784001 - 02- 03 (ER)
Hemando Siles Ave.  2784750-2784755
Calle 7 - OBRAJES 2782922

(T) Clinica Cemes (PED/Obst.) 430350/60/70/80
6 de Agosto Ave., Sopocachi 431793 (Fax)

Clinica "Trauma Klinik" 771819, 771904
Claudio Aliaga Bloque "F" # 12, San Miguel 772014 (Fax)

* Raul Pinto, M.D. (U.S. trained) 442058 (Office)
2342 Arce Ave. 076-20880 (Cell Phone)
441776 (Fax)

* Dr. Jean A. Floru M. 430097 (Office)
Las Dos Torres Bldg. Mezzanine
2577 6 de Agosto Ave

*(T) Dr. Octavio Aparicio 431133 (Office)
UNIMED, 2630 Arce Ave. 012-92484 (Cell Phone)

Dr. Luis Valda 442748 (Office)
"MEDI-DERM", # 6, Belisario Salinas Building 442747 (FAX)
350 Belisario Salinas St., Sopocachi

* Dr. Walter Escobar Terceros 360668 (Office)
Copacabana Bldg, 4th floor, Office No. 402 012-31932 (Cell Phone)
273 Loayza corner Mercado

Dr. Jorge Rojas Silva 441706 (Office)
Calama Bldg., 1 st floor - Office 1 015-27666 (Cell Phone)
Heriberto Gutierrez St.

*Dr. Guido Villa Gomez (Endoscopy) 431133 (Office/Fax)
UNIMED - 2630 Arce Ave. 015-22747 (Cell Phone)

Dr. Rafael Ortuño
Edif. Manantial 1er piso Of. 10 & 11 368242 (Office)
20 de Octubre Ave. 2223 015-23714 (Cell Phone)
Instituto Gastroenterologico Japonés 246424

*Dr. Hugo Castellanos Hochkofler 431133,430512 (Office)
UNIMED, 2630 Arce Ave. 012-95626 (Cell Phone)

Dr. Jorge Terrazas 411212 (Office)
CERMED, Ecuador St. corner Rosendo Gutierrez St. 015-62850 (Cell Phone)

*(T) Dr. Fernando Patiño 430697, 431664 lllimani Bldg. - 2nd. Floor, Office 2D - Arce Ave. 012-25625 (Cell Phone)

Dr. Nelson Tejada 443636 (Office)
El Estudiante Bldg. 2nd. Mezzanine 015-24434 (Cell Phone)
Batallon Colorados St.

*Dr. Luciano Bances Flores 443351 (Office)
Fernando V Bldg., 12 Floor, Of. 1202 012-26442 (Cell Phone)

Dr. Gustavo Sanchez. 353331, 390103
16 de Julio Bldg., 2nd floor, # 203, El Prado 012-94612(Cell Phone)

CEMESUR, Calle 21 and Ballivian Avenue, Calacoto 792357

Dr. Javier Endara 434775 (Office)
Escorial Bldg, Arce Av. Corner Cordero 012-96733 (Cell Phone)

* Dr. Joaquin Arce 441717, 433060
MEDICENTRO, 2440, 6 de Agosto Ave. 019-39185 (Cell Phone)

Dr. Jaime Linares 441135 (Office)
El Condor Bldg., #602, 2440, 6 de Agosto Ave. 015-24320 (Cell Phone)

*Tamara Nelkenbaum (U.S. Trained) 772206 (Home)
8172 Calle 13, Calacoto 015-64309 (Cell Phone)

 

 

OB/Gyn

*(T) Dr. Marcelo Koziner Udler (Post Advisor) 201410, 200860
Mariscal de Ayacucho Bldg. 3rd floor, # 313 798243 (Fax)
Loayza St. almost corner Camacho Ave 015-20111 (Cell Phone)
8514 Basaure Building, Calle 21, # 1 D, Calacoto 795668, 798233
Also early in the morning: CEMES CLINIC 430360 (Clinica)

*(T) Dr. Jaime Teran (U.S. Trained) 796589 (Office)
Rhesus Bldg., 1367 G. Rene Moreno St./Claudio Aliaga St. 015-38641 (Cell Phone)

*(T) Dr. Ovidio Suarez 431501 (Office)
lllimani Bldg., lst floor, Office B 431578 (Office/Fax)
Arce Ave. corner Campos 012-92535 (Cell Phone)
Mornings: Clinica Cemes 430360/ 50

*Dr. Fernando H. Murillo L. (U.S. Trained) 794272 (Office)
Rhesus Bldg., 794272 (Fax)
1367 G. Rene Moreno St. corner Claudio Aliaga St. 012-42769 (Cell Phone)
San Miguel (Next to Trauma Klinik) 342277 (Office)
San Pablo Bldg., # 905, 1479,16 de Julio Ave. (El Prado) 342277 (Fax)

*Dr. Gonzalo Murillo (Some U.S. Training) 790080 (Office)
Torre Ketal, 15th Street/Sanchez Bustamante - Calacoto 799579 (FAX)
"Las Dos Torres" Bldg. 434289 (Office)
Av.6 de Agosto corner Pinilla, # 1.3 012-96954 (Cell phone)

*Dr. Vania Garcia 792357(Office)
CEMESUR, Calle 21 corner Av. Ballivian, Calacoto 015-63873 (Cell phone)

 

Dr. Jorge Callisperis 784001,784002
Clinica del Sur, 3539 Hernando Siles Ave., Obrajes 015-67668 (Cell Phone)

Dr. Adolfo Land 784001,784002
Clinica del Sur, 3539 Hernando Siles Ave., Obrajes 012-33956 (CellPhone)

Dr. Sergio Iriarte 784001, 784002
Clinica del Sur, 3539 Hernando Siles Ave., Obrajes 015-34944 (Cell Phone)

*Dr. Alejandro Reyes (Knee) 784001, 784002
Clinica del Sur, 3539 Hernando Siles Ave.,Obrajes 012-93467(Cell Phone)
Afternoons: 2207 Ecuador Ave., Sopocachi 411212 (Office)

*Dr. Luis Alberto Ballón 771819, 771904
TRAUMA KLINIK, Claudio Aliaga St., Bloque F # 12 772014 (Fax)
San Miguel, Calacoto 079-34335 (Cell Phone)

Reynaldo Flores (Needs Doctor. s order) 784001 - 784002
Clinica del Sur

* Dr. Cesar A. Velarde (U.S. Trained) 795652 (Office)
8345 Calle 21, San Miguel 794485 (Fax)

*(T) Dr. Juan Enrique Wantig A. (U.S. Trained) 796802 (Office)
E 2 Montenegro Ave., # 2, San Miguel 431469 (Fax)
012-96550 (Cell Phone)

*(T) Dr. Fernando Sugastti (U.S. Trained) 792357, 796506
CEMESUR, Calle 21 and Ballivian Avenue 771573 (Fax)
Calacoto 012-98026(Cell Phone)

Dr. Patricio P. Andrade 784001 (Clinica)
Inchauste Zelaya Bldg. . Of. # 100 319996 (Office)
1940 Villazon Ave. (Plaza del Estudiante) 015-36961 (Cell Phone)

*(T) I. Andreas G. Barragan 770301 (Office)
CEMESUR, Calle 21 corner Ballivian Avenue, Calacoto 015-20021 (Cell Phone)
Tues. & Thurs. Clinica Del Sur 5:00-7:00 784001 (Clinica )

*Dr. Vicente Arze
Mornings: 9:00-10:00 Clinica del Sur 784001 (Clinica)
Afternoons: 6:00-8:00pm 360581 (Office)
Edificio El Condor - Batallón Colorados St. - 015-20040 (Cell Phone)

Dr. Gonzalo Solis 430732 (Office)
Mercurio Building, 6 de Agosto Ave./Cordero St.

Dr. Ricardo Ramos 431355 (Office)
Mercurio Bldg. # 101, 6 de Agosto Ave./Cordero St.

* Dr. Rodolfo Lopez Hartman 712552 (Office)
FISIO CLINICA, Gral. Lanza Ave./Calle 19, Achumani 012-17269 (Cell Phone)
Vice Ministerio de Prevension, Hr. 9:00-6:00 PM 335478 (Office)

*Dora Beatriz Pinelo N. (Dotty) (U.S. Trained) 355027 (Office)
953 Mariscal Montenegro St., San Miguel 792630 (Home & Fax)
015-67006 (Cell Phone)

*Francisco Ormachea (U.S. Trained) 771333 (Office)
Shopping Sur - Mezzanine - Calacoto 012-41950 (Cell Phone)

*Susana Carranza (U.S. Trained) 771813 (Office/Home)
Calle K # 4A, Auquisamana

Dr. Enrique Cortez 441696 (Office)
lllampu Bldg., 2132 Arce Ave. 015-63474 (Cell Phone)

* Dr. Nils Peña 430847 (Office)
Mercurio Building, 2809, 6 de Agosto Ave./Cordero St. 012-96663 (Cell Phone)

* Dr. Ramiro de la Rocha (U.S. Trained) 433432 (Office)
6th floor - Mercurio Bldg. 433546 (Office)
6 de Agosto Ave. corner Cordero 012-98094 (Cell Phone)

* Dr. Alvaro Balcazar (U.S. Trained) 431133 (Office)
UNIMED, 2630 Arce Ave. 015-58366 (Cell Phone)

*(T) Dr. Jorge Aguirre (American Academy of Periodontics) 430496, 432682
Illimani Bldg., 2677 Arce Ave./Campos St. 015-34089 (Cell Phone)

Dr. Celina Cuellar 799792, 798518
Aranjuez Bldg., 1044 Julio C. Patino St., Calacoto 798283 (Fax)

*Dr. Elmer Mollinedo 79-2512 (Office)
Clinica Odontologica Calacoto Bldg. 015-20160 (Cell Phone)
8215 Calle 21 . 1^st. Floor 792512 (Fax)

Dr. Antonio Abularach (Orthodontist) 433600 - 430919
Mercurio Building, 6 de Agosto Ave./Cordero St.

*Dr. Jose Artieda 432116, 430100
Mercurio Building, 6 de Agosto Ave./Cordero St. 012-96307 (Cell phone)

*Dr. Carolina Montellano
Illimani Bldg., 2677 Arce Ave.

Clinica Radiologica
"RX LIMITADA - CESAR CARRASCO" 440468 (Office)

Dr. Raul Patzi 440125 (Office)
Montevideo Bldg. Arce Ave. corner Montevideo

Lab -Tek 431988 - 431542
lllimani Bldg., Mezzanine Office # 4

Lab-Tek - Calacoto 784444 (Office)
Ballivian Ave. comer Calle 14

Bioquimica 434775, 434781
El Escorial Bldg.,Arce Ave./Pasaje Cordero # 127

Lab Clinics 430846, 434571
Iturri Bldg., 6 de Agosto Ave/Campos St.

Pathology Lab 434865 (Office)
El Escorial Bldg., # 115, Arce Ave./Cordero St.

Carlos V 430490
Mercurio Bldg., 6 de Agosto/Cordero St.
P.O.C. Dra. Luz Clavijo de Salamanca
Gloria 711501, 713030
Av. Garcia Lanza/Calle 16, Achumani
P.O.C. Dra. Gloria Helguero

CEDIMED (Health Unit sets up appointments) 225694, 245063
Av. Bush 1126 - P.O.C. Dr. Raul Patzi

CEMDI (Dr. Juan Carlos Nemer) 432373, 433415
Av. 6 de Agosto 2530

Ericka Eickhoff (U.S. Trained) 795652 (Office)

Clinica del Sur 782696 (Office)
3539 Hernando Siles Ave. (Obrajes)
P.O.C. Magda Brito

* Ximena Cabezas de Peña (U.S. trained) 797703 (Office)
Cibeles Bldg. - Apartment 2
Los Sauces Ave. corner Calle 14

CILAP
Dr. Virginia Calderon
CEMES Mornings (Emergencies) 434728 (Clinic)
1881, 6 de Agosto Ave.
Victoria Bldg., Arce Av./Goitia St. 440060 . 440605

Dr. Eric Rada Uría 392978 (Office)
Petrolero Bldg. 015-34033 (Cell Phone)

Dr. Jaime F. Alcazar Peix 327865 (Office)

Dra. Silvia Cruz de Alcazar 012-27277 (Cell Phone)
2338 Sanchez Lima Av. . Sopocachi

Catherine Blumhorst can be reached at the Medical Unit in Santa Cruz, Calle Guemes #6 Este, on Monday through Friday from 8:00 a.m. to 10:00 a.m. For emergencies contact Cathy (#013-61289), Dr. Foianini (# 016-27647), or the Duty Nurse in La Paz (# 012-24861.)

Dr. Jorge Foianini, F.A.C.S., (03) 362211 (Clinic)

U.S. Board Certified, American Citizen 366001/02/03/04/05/06

Av. Irala 468 016-27647 (Cell Phone)

Clinica Foianini (03) 362211

Av. Irala 468 365577 (FAX)

P.O.C. Dr. Jorge Foianini

Clinica Foianini (03) 362211

P.O.C. Dr. Foianini 016-27647 (Cell Phone)

Dr. Marcelo Arano 361032 (Office)

C/La Paz 523 013-94284 (Cell Phone)

Dr. Carlos Callau 539191 (Office)

Av. Ejercito Nacional 538811 (FAX)

Dr. Carlos Futchner 330029 (Office)

Guemes Este 4 013-48811 (Cell Phone)

Dr. Keen Coca 536111 (Office)

Ingavi, 641 016-25268 (Cell Phone)

Dr. Jaime Niño de Guzmán 370808 (Office)

Republiquetas, 684 013-92256 (Cell Phone)

Dr. Carmelo Rivero Lens 335650, 32444

Lemoine, 3279

* Dr. Jorge Foianini, FACS (Post Advisor, U.S. trained) 366005 (Office)

Av. Irala, 468 016-27647 (Cell Phone)

Dr. Marco Garafulic (U.S. trained) 422626 (Office)

Jaime Mendoza, 45 (Av. La Salle) 016-25301 (Cell Phone)

Dr. Gonzalo Ostria, FACS 329578 (Office)

Ingavi/Independencia (Ga. Cent. Of.) 016-49390 (Cell Phone)

Dr. Gonzalo Aviles 365027 (Office)

Arenales, 631 016-22130 (Cell Phone)

Dr. Hernan Velarde 544040 (Office)

Av. Mons. Costas, 265

Mornings: Instituto Gastroenterologico Boliviano Japones 256791,259198,259638

Afternoons: ENDOCORP 254799

Office . SERVIMED Bldg. 297829/30, 283644

777 Baptista 283644 (FAX)

017-20234 (Cell Phone)

MEDICAR Emergency Ambulance Service (Ground Ambulance)

942 Ramon Rivero (04) 533222 and 181

P.O.C. Dr. Morgenstern . 017-20234 (Cell Phone)

Dr. Juan Pablo Barrenechea, FACS 229407,250928,231403

Director Clínica Belga

Dr. Alejandro Sauma, FACS 231403 (Office)

Clínica Belga

Dr. Alberto Requena 223177 (Office)

Edifício Tardio

Dr. Silvester Arze 229407,250928 (Office)

Clínica Belga

Dr. Rodolfo Quiroga 485284 (Office)

017-23633 (Cell Phone)

Dr. José Valderrama (U.S. trained) 250911 (Office)

Ramón Rivero #882 014-95921 (Cell Phone)

Dr. Joaquin Lopez 223240 (Office)

Jacaranda II, Calle Ecuador/Ayacucho

Dr. Eduardo Lujan 222263 (Office)

Paccieri #684

Dr. Gaston Moscoso 297829/30 (Office)

777 Baptista St. 014-99111 (Cell Phone)

Dr. Fabiana Mirtha Pena 290040 (Office)

777 Baptista St. 014-46763 (Cell Phone)

Dr. German Urenda 297829/30 (Office)

Baptista # 777 017-27052 (Cell Phone)

Dr. Gerd Simon (Trained in Germany) 295858 (Office)

Av. Santa Cruz/Beni