"We Just Live Here": Health Decision Making and the Myth of Community in El Alto, Bolivia

Jerome Winston Pettus Crowder

PhD Thesis. 1998

This research focuses on the concept of community as it is defined by both a Primary Health Care clinic and local Aymara speaking residents in El Alto, Bolivia. Neighborhoods within northern El Alto are filled with people who hail from across the Andean Altiplano, and bring with them differing worldviews. Although residents of the periurban barrio of Villa Huayna Potosi may appear homogenous to outsiders and constitute a community, local residents share little with their neighbors and instead base their community upon kinship ties and political affiliations which are manifested in trust.

When individuals in El Alto fall ill they turn to people they trust to help them heal. Huayna Potosi is a medically pluralistic environment. While previous health decision making models have focused on cost-benefit analysis, I argue that residents base their decisions on trusting the health care provider to understand their needs. All persons make health care decisions, providing an excellent window through which to view where residents place their trust and thus reflect their construction of community.

The World Health Organization (WHO) initiative for Primary Health Care (PHC) promotes the integration of health care facilities with local communities. The private, nonprofit local health care center PROSALUD subscribes to PHC guidelines and provides preventative and curative health services to residents who live in Huayna Potosi and five surrounding barrios. I argue that this catchment area is not a community as defined by the people who live within the boundaries of the barrios because it presumes that ascriptive similarities create community. This and other assumptions about the residents of Huayna Potosi reflect the differences between how the PROSALUD administration and its client base perceive community, which lead to greater misunderstandings between the residents and the clinic.

Fieldwork was carried out in Huayna Potosi between 1995 and 1996 and incorporated a variety of ethnographic methods including participant observation, the review of clinical medical histories, and the administration of interviews with health center clients, local neighborhood households and health care professionals. The open ended questions in the survey instruments gathered data on demographic composition, illness history, and choice utilization of the respondent individuals and households. Consistent with the research focus on community, a majority of respondents reported that trusting their health care specialist was of primary concern when help-seeking.
In the case of PROSALUD in Huayna Potosi, residents most frequently use the clinic only in dire situations. Because the residents of Huayna Potosi and the clinic do not similarly define community, the clinic cannot function to its full potential, not do the residents entirely benefit from the presence of the clinic. Specific recommendations are provided which outline how the clinic may better understand residents' views of community and address their needs. This research supports the hypothesis that individuals in El Alto define their community through kinship ties and political affiliations which are manifested in trust and reflected in their health care decisions.