PATRICIA BLANCO

Bolivia,

Patricia Blanco is showing Bolivian communities how to improve their health by addressing three overlapping factors: widespread poor nutrition, which the government has long identified as a development priority; diabetes, which is common, largely untreated, and controllable by diet; and budget devolution, which enlarges the potential for prepared communities to secure funding for healthcare programs they choose to defend.

This profile below was prepared when Patricia Blanco was elected to the Ashoka Fellowship in 2003.

INTRODUCTION

Patricia Blanco is showing Bolivian communities how to improve their health by addressing three overlapping factors: widespread poor nutrition, which the government has long identified as a development priority; diabetes, which is common, largely untreated, and controllable by diet; and budget devolution, which enlarges the potential for prepared communities to secure funding for healthcare programs they choose to defend.




THE NEW IDEA

Patricia is involving communities in every aspect of breaking down the critical health problem of nutrition. Teachers and high school students are gathering information that has not been systematically collected before about what families actually eat in a day. With Patricia's training, community members create nutrition programs that will last because they have designed them to fit needs they have assessed themselves, and because they are learning how to secure allocations in the budgets of their municipalities to fund the programs. While her trainees interview people about what they eat, they are also able to identify people at high risk for diabetes, which, in the type common in the Andean region, is manageable chiefly through diet. Thus, Patricia's work deals with two health problems at once. She sees diabetes as eminently treatable under the "umbrella" focus on food and nutritional security.

Patricia works with doctors, nurses, community health promoters, mothers, mayors, and other local leaders, but her primary training focus has become normalistas–university students who are preparing to become teachers. The student teachers are enthusiastically studying her principles of diagnostics and diet change. They have encouraged a university with an exclusive food-service contract to make room for a health bar and have made attractive presentations in villages about eating well. Most important, they get nutrition education into the classroom. There, they are in daily contact with children, whom Patricia sees as uniquely able to educate their mothers, the food preparers.




THE PROBLEM

Research by the World Food Program in 2000, and by other groups that have concentrated on Latin America, has revealed dietary findings with troubling implications both for personal well-being and development prospects of countries where citizens are poorly nourished. Only 12 percent of Bolivia's families consume the 2,250 calories daily per person that are thought to be the bare minimum energy requirement. Their daily food consumption consists of a majority of carbohydrates and only 10 percent protein. WHO/PHO studies indicate that Bolivia has seen no substantial change in that ratio in 40 years, even though international health bodies agree that protein intake should be 20 percent. High-level government officials agree there is a need for improved nutrition because of extremely high rates of malnutrition throughout the country, particularly in the countryside, where studies show one of the poorest rates in South America. However, a nutrition program for pregnant women and children up to 5 years-of-age languishes, and a 1996 treaty with the FAO has never been put into action.

Meanwhile, high carbohydrate consumption with corresponding elevated blood sugar exacerbates diabetes, which, after malaria, is the most common disease in Bolivia. Almost all diabetics in the Andean region have Type 2 diabetes, which they could potentially manage through diet and exercise and avoid devastating late-stage conditions like heart failure, blindness, strokes, and gangrene. However, most of the estimated 750,000 diabetics in Bolivia cannot practice prevention because there are no healthcare systems for diagnosing the disease; they do not even know they have it. There is some evidence that people of Hispanic origin may have a heightened risk of diabetes–the Center for Disease Control in Atlanta has urged community assistance in spreading information in Spanish-speaking communities.

With regard to health programs and also more broadly, Bolivia's political discourse is trending toward an emphasis on popular participation. In 1994 the government passed a Popular Participation Act which devolves budgets to municipal control and obliges municipalities to hold budget discussions where citizens can listen and participate. But in reality people do not know how to participate. While past official analyses about nutrition have concentrated mostly on agricultural productivity, starting in the 1990s health-related programs started singling out communities and students (half of Bolivia's population is under 18) as the key to change. The Pan American Organization of Health, of which Bolivia is a member, drew up a plan in the late 1990s for adolescents to strengthen health programs for their age group. In recent years an experiment called "Education for Health" used doctors in their one year of required service in outlying areas to train high-school students to be health innovators in their communities. The program showed great promise, but lapsed when the year ended. How to develop truly community-driven programs that will outlast temporary investment from the outside has remained elusive.




THE STRATEGY

In a milieu where there is a lot of rhetoric and concern about both nutrition and public participation with scant definition of how to make things happen, Patricia is demonstrating how to improve the one by using the other. She has created training programs for different groups in the community.

Recognizing the influence that teachers can have in their classrooms, she began classes at a university in Cochabamba for teachers in training. She teaches them how to look at the communities in which their students live and to diagnose and determine key nutritional problems. The next step is to think creatively about how to solve these problems and to work within the provisions of the Popular Participation Act to draw up plans of how to execute their bright ideas and generate proposals to fund them. According to the act, community members who belong to unions like the teachers' union or to community organizations may engage in budget discussions on their group's behalf, and the teachers qualify. Patricia is helping them to learn how to read budgets, look at past expenditures, and negotiate for allocations.

When she works with the teachers in training, Patricia uses three key materials: the government manual on popular participation, the Chilean popular participation guide, and her own writing about her earlier similar work in Argentina where she developed processes to successfully engage communities in analyzing problems related to food. Student teachers from her initial three groups have gone into their communities and organized fairs to teach town members about healthy eating habits; they have gone into local government-sponsored dining halls and put on puppet shows to teach mothers and children about the importance of including vegetables in their diets; and they have convinced the university to modify its agreement to purchase dining hall food from a single company in order to open up their own snack bar to sell only healthy foods. Though any one class is not usually offered so often, the university has asked Patricia to give this class to 15 groups of students in all subject areas. She believes her training program has had a motivational effect on the teachers because it helps them to discover for themselves ways that they can truly have an impact on their students beyond just transferring information to them. She is planning to present her program to the national Congress of Teaching Colleges to get them to adopt her program as part of a standard curriculum for teachers and to replicate it throughout the country, a move which has the full support of the university where she teaches.

In the second stage of development of Patricia's training program, the same teachers that study with her in teaching colleges work with high-school seniors, teaching them the basics of nutrition and diabetes and the diagnosing questions and discussion processes that Patricia has developed. These students then go into the communities and survey their neighbors about their eating habits and information about past illnesses, delivery of exceptionally large babies, and other relevant information. This is a quick and efficient way to detect diabetes. It is also an important way to track and study specific food and nutrient intake in Bolivia, something that has not been done with any regularity anywhere in the country. The high-school students also train the families about proper eating habits when they conduct their visits.

In order to stimulate general public awareness about nutrition, Patricia is developing radio and television campaigns about eating habits. They are presented in Quechua as well as Spanish. The radio programs air in conjunction with Ashoka Fellow Fernando Andrade who has a community radio program that reaches the poorest (and probably most malnourished) populations.

Using tools similar to the ones she has developed for teachers, Patricia also holds training programs for underused local health promoters, local governing officials, and nurses and doctors in local clinics. The latter two groups also learn how to conduct primary treatment of diabetes and what to do to prevent cases of diabetes from becoming more serious.

In the process of holding one-day nutrition training for local authorities, Patricia also introduces them to the problems of diabetes and the actions they can take to prevent malnutrition and related illnesses in their towns. In one community where Patricia offered the training, the mayor was so convinced by her arguments that he declared that local bakeries were no longer to prepare white bread, but rather had to mix their bread with tarhui, a high-protein Andean grain. She has also established a relationship with a senator who has two diabetic relatives to push through a law that would provide diabetics with the medicine and testing devices they need to prevent their cases from becoming more serious.

Once diabetics are diagnosed in a community, Patricia also works with them as a group. She teaches them about their illness and how to use their diet to control it. And in the same way that she works with teachers, she trains the diabetics how to generate health projects to take care of their health needs and to secure funding for these projects. When she was doing similar work earlier in Salta, Argentina, one group of diabetics decided that they could create their own dining hall to serve the kind of food they needed to be healthy and to sell that food to outsiders to promote better health and also generate income for themselves to be able to purchase their testing devices. The community groups that Patricia formed years ago in Salta are still operating. They are so strong that even though Patricia left for Bolivia, the community continued to push for a law that introduces basic clinical provisions. She had started the process, but they carried on and got it passed, ensuring primary care and testing devices for all diabetics in Salta.




THE PERSON

Patricia has always dedicated herself to helping people, a practice that, during the time she was coming of age in Argentina, caused suspicion about leftist leanings. Regardless, she managed to do so with a low profile by writing about social needs and engaging in socially oriented activities through a Catholic youth group.

Patricia's aunt (and godmother) was a role model and second mother to her. She went to medical school for three years but eventually had to drop out in order to take care of her younger siblings. Her father, Patricia's grandfather, was a doctor whom she never knew, but she heard stories about how he took care of the poor without charging them. Patricia says that she knew she wanted to be a doctor from the age of 5.

Patricia was diagnosed with Type 1 diabetes in 1984. The next year, she graduated from medical school and chose to specialize in endocrinology and diabetes.

Family circumstances have taken Patricia back and forth between her home country of Argentina and her adopted home Bolivia, but, wherever she is, she dedicates herself to the prevention and treatment of diabetes. She first began the precursor to her current program in 1994 in Tarija, Bolivia, and, in 1996, she enhanced and adapted it in Salta, Argentina. In order to further her goals of diabetes prevention and treatment, Patricia complemented her medical degree with a master's degree in management and administration of health services. Later, when she saw that lasting impact would not happen unless the community was directly involved in solving its own problems, she went to Cuba for post graduate courses in community development. Her work in Argentina was so successful that she reached national impact by formulating and ensuring the passage of a National Diabetes Law and by getting one of the public insurers to adopt her diabetes program.

She recently moved back to Cochabamba, Bolivia, where she is refining her model to include an express nutritional component and adapting it to the bleaker Bolivian context.




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