EURJ Volume 14

EURJ

Emory Undergraduate Research Journal Volume XIV

Spring 2018

La Paz, Bolivia

about EURJ

The Emory Undergraduate Research Journal (EURJ) is an annual print and online publication that accepts research manuscripts written by Emory undergraduates from all academic disciplines. EURJ provides a venue for students to showcase their high quality, original research while fostering interest in undergraduate research. Research can be submitted up until two years post-graduation. EURJ was founded through generous support by the Office of Undergraduate Education and is continuously supported by the Media Council.

Emory Undergraduate Research Journal Volume XIV Spring 2018

1655 North Decatur Road, Atlanta, Georgia 30322

A Letter from the Director of Undergraduate Research Programs The College of Arts and Sciences at Emory has a long history of supporting undergraduate exploration, creativity, and experiential learning. As the director of the recently restructured Undergraduate Research Programs, I am excited to support the university’s mission to foster an engaged community of undergraduate researchers. I am committed to facilitating opportunities for students to explore their interests and passions through scholarly inquiry and experiential research.

As the faculty advisor of EURJ, I see our mission to promote and sustain a diverse and nuanced community of researchers realized in the student profiles, articles, and features. This volume demonstrates the vibrancy of research occurring in the humanities, social sciences, arts, and sciences. In showcasing both the actual process of research and broadening the narrative of what research is and who conducts it, this issue of EURJ seeks to highlight a broader community of undergraduate researchers.

The editors have captured the zeitgeist of movement that the contributors to this volume of EURJ, energized by current events on a local, national and international scale, have drawn upon in their exploration and construction of knowledge. Through research, undergraduates are forming connections. The ways in which Emory undergraduate students’ access and contribute to the academic landscape, as seen in this journal, are numerous and varied as they pursue curiosity both in the classroom and beyond.

Along with the reimagining of EURJ, Emory is witnessing a bubbling of spaces of undergraduate intellectual dialogue. These spaces in unison highlight and help to sustain a community of students engaged, drawn to inquiry, and fueled by the desire to discover, connect, and transform.

I am proud of the hard work of the editorial team and the contributors. I hope this issue sparks your curiosity, fuels conversation, and broadens your understanding of research at Emory.

Folashade Alao, PhD Associate Director, Emory Undergraduate Research

Editorial Board 2017 - 2018

Editor-in-Chief Josh Buksbaum Managing Editors Merry Chen Steven Chen

Design and Layout Merry Chen Katharine Yan Steven Chen Ursula Choi Nafis Ahmed

Humanities Editor Ana Marie Kilbourne

Website Editor Abhinav Nair

Natural Sciences Editor Allison Irwin

Photographer Steven Chen

Social Sciences Editors Amulya Marellapudi Petar Zotovic

Copy Editor Ajwad Khan

Treasurer Josh Buksbaum

Special Features Natalia Brody

Join us!

Email eurjstaff@gmail.com with any questions or comments!

Apply for a position on our staff or send in your research paper for publication in the Spring 2019 issue. Email us for information regarding submission guidelines and deadlines.

Photos by Steven Chen

A Letter from the Editor: To our readers, We are pleased to present to you Volume 14 of the Emory Undergraduate Research Journal (EURJ). This year’s edition continues with our tradition of providing an interdisciplinary platform for undergraduates to showcase their research in the natural sciences, social sciences, arts, and humanities. EURJ seeks to highlight the intellectual vitality of the undergraduate students and recognize their scholarly work in a manner that fosters discussion. The articles in this issue were selected to provide a small glimpse into the variety and breadth of some of the research opportunities and topics being pursued by Emory undergraduates. We hope to only strengthen our tradition of celebrating research with our Spring 2018 issue.

While highlighting the research on Emory’s campus, Volume 14 also displays the talent of our graphics and design team, an asset we hope to use more of as we increase our on-campus presence through the use of a website and social media. You can look forward to interactive content and frequent posts on our website in the near future.

This year, we received an extremely wide range of submissions, from geopolitical climates across the world to analyses of intricate molecular systems. Selecting the most fit candidates for publication was difficult, as the work was all very strong. However, we wanted our Spring 2018 issue to capture some of the research that Emory students are performing to change the world NOW. What problems or challenges are being grappled with across political and socioeconomic boundaries, and how can we address them? By reading about how Emory students are involved in research focused on cryptocurrency security, women’s mental health, opioid addiction, suicide prevention, and the Chagas virus, we hope to encourage and challenge you to become involved in research. Like our authors, we hope you will become passionate about improving the world, and pursue research to improve this goal.

I would like to express my gratitude to all the people whose tireless work and support have made this journal a reality. First, I would like to thank Dr. Alao, our faculty advisor, who has provided us with the resources and insight to ensure the success of our journal. I also want to extend a huge thank you to all the authors and their mentors, whose research propels this journal and inspires us all. Lastly, I want to thank our own editorial staff. Together, your creativity and dedication brought hours of research to life, and made this journal a possibility.

On behalf of the entire 2017-2018 EURJ staff, we would like to thank you for reading our journal. We hope you enjoy the exceptional work that our Emory undergraduate students have produced.

Josh Buksbaum Editor-in-Chief

TABLE OF CONTENTS 8

Hacking the Bank: Do Bitcoin Security Breaches Lead to Price Drops?

16 23

Gendered Patterns of Mental Health Attribution: An investigation into accounts of women’s stress in Léogâne, Haiti

Student Spotlight: Latha Karne

24 34

Social Class and Suicide: Income Versus Education as Measures of Class

Enfermedad de Chagas en Bolivia

Pexels

Hacking the Bank

Do Bitcoin Security Breaches Lead to Price Drops?

David Hervey

Creative Commons

Introduction

security breach leading to the theft of customers’ and

Perhaps the most-cited concerns of Bitcoin the exchange’s own funds. skeptics are the security of the virtual currency’s online exchanges and wallets, as well as the generally unregulated nature of Bitcoin-denominated transactions. To justify that these worries are grounded in fact, many point to the collapse of Mt. Gox in February 2014, which preceded a price drop of about 40% over the next two There is, admittedly, little agreement among eimonths,1 from which Bitcoin did not recover for almost a year and a half. Although the Mt. Gox hack and bank- ther Bitcoin believers or critics as to what constitutes seruptcy provide some anecdotal support for the views of curity or lack of it. Few observers, if any, have voiced seBitcoin skeptics, there has been little published quanti- rious concerns about the blockchain technology which tative research to either support or refute the position Bitcoin uses to verify transactions. Indeed, even some that security breaches contribute to the risk of holding of Bitcoin’s biggest skeptics have said that blockchain be useful for the finance industry more generalBitcoin even for those whose holdings are untouched could 3 by the breaches themselves. Although some researchers ly. Worries about Bitcoin’s security are usually focused have asserted that hacks and scams have not affected on the risk of online exchanges or wallets being hacked, the USD-BTC exchange rate, they have not published or Bitcoin’s anonymity and lack of regulation opening the data or methods from which they drew this conclu- the way for scammers to conduct Bitcoin-denominated sion.2 The available data, however, does not support the fraud with relative impunity. There are numerous precGox collapse to the more assertion that hacks, scams, and other security breaches edents for this, from the Mt. 4 recent hack of the Bitfinex, which took over from Mt. have an impact on the price of Bitcoin.

Verifying whether the security concerns of Bit- Gox as the largest Bitcoin exchange. Yet the contrast becoin skeptics are grounded in fact has significant rel- tween the aftermath of Mt. Gox’s collapse and that of evance for the numerous investors trying to decide the 2016 Bitfinex hack calls into question the concluwhether to enter the market for Bitcoin. As Cboe and sion that Bitcoin skeptics reach: that security breaches are a risk to the entire CME, two large exchangmarket, rather than just es, begin selling Bitcoin the investors whose coins “Security breaches are a risk to the futures this month, with are hacked. To quantify entire market, rather than just the Nasdaq following suit the return on Bitcoin, I next year, many more investors whose coins are hacked.” use daily historical data investors will be able to for the price of Bitcoin make short and long bets traded on Bitstamp, a on the cryptocurrency exchange with data aggregated by without relying on often-unregulated online exchanges. Luxembourg-based 5 Yet, despite the market being opened up to more tradi- Quandl, a website which provides financial data. For I used a thread on tional investors than those who have previously shown information about security breaches, 6 interest in Bitcoin, the concern that security breaches the Bitcointalk.org online forum. Despite this being may lead to market-wide downturns remains. I exam- an unorthodox source of data, it has been used in preand peer-reviewed studies of Bitcoin ine this concern against the available data in the hope vious academic 7 of determining whether such a security-related bear exchange risk. It is rare for academic or financial remarket for Bitcoin is possible, or if it is a myth derived searchers to turn to an online forum for data, but the from a misreading of the Mt. Gox bankruptcy, when the post here is the most comprehensive data source preslargest online exchange of Bitcoin went offline, taking ently available on 8Bitcoin hacks and scams, as noted by many customer funds with it, in the wake of an alleged other researchers, although there is certainly room for Creative Commons

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1 2 3 4 5 6 7 8

Daisy Maxey, “Should Individuals Invest in Bitcoin? In a Word, No.,” Wall Street Journal, October 11, 2017 Tyler Moore and Nicolas Christin, “Beware the Middleman: Empirical Analysis of Bitcoin-Exchange Risk,” in International Conference on Financial Cryptography and Data Security (Springer, 2013), 25–33.

“Jamie Dimon Slams Bitcoin as a ‘Fraud,’” Bloomberg.Com, September 12, 2017 Nathaniel Popper, “Warning Signs About Another Giant Bitcoin Exchange,” The New York Times, November 21, 2017 BitStamp, Dec 5, 2017 “BTC/USD on BitStamp,” Quandl https://www.quandl.com/collections/markets/bitcoin-data Dree12, November 16, 2014, “List of Major Bitcoin Heists, Thefts, Hacks, Scams, and Losses” Bitcointalk.org Amir Feder et al., “The Impact of DDoS and Other Security Shocks on Bitcoin Currency Exchanges: Evidence from Mt. Gox,” in 15th Workshop on the Economics of Information Security (WEIS), 2016.

Tyler Moore and Nicolas Christin, “Beware the Middleman: Empirical Analysis of Bitcoin-Exchange Risk,” in International Conference on Financial Cryptography and Data Security (Springer, 2013), 25–33.

future research to create a more up-to-date database of Bitcoin security breaches.

I specifically looked at the price of Bitcoin and incidence of security breaches from January 1, 2012, to March 31, 2014. I chose this period because it is the time during which there is (publicly accessible) reliable data for both Bitcoin price and security breaches. Some early breaches seem to be the result of imperfect or underdeveloped “best practices” for storing and trading Bitcoin, time during which there is (publicly accessible) reliable data for both Bitcoin price and security breaches. Some early breaches seem to be the result of imperfect or underdeveloped “best practices” for storing and trading Bitcoin, and Bitstamp did not have enough trading volume on some days in 2011 to say that the data for these days accurately reflects the price of Bitcoin on that day.

I chose the end date of the study to reflect the end of the period for which there is reliable data about Bitcoin-related security breaches. Despite numerous hacks, scams, and other losses in the dataset, I find that these events did not have a significant impact on the price of Bitcoin during the time-period examined, and that this finding is robust to a re-specification of my model.

Findings

Strikingly, even on days with security breaches, Bitcoin gained value on average. Furthermore, security breaches did not have a statistically significant effect on the rate of change in Bitcoin price, as seen in the table below:

Bitcoin appeared to increase in price at a higher rate on days with security breaches, but this effect was not statistically significant and was the result of determinants of Bitcoin price which were not included in the model.

To check robustness, I also coded a dummy variable for if there had been a security breach in the previous week. This is to reflect the fact that security concerns may not be accounted for by the market in the same day of trading as a breach occurred: there may be significant and sustained decreases in price after the initial breach, but not necessarily on the day that the Methods

As noted above, I used data on the USD-BTC breach was made public. However, my findings in the Exchange rate on the exchange BitStamp, accessed robustness check were unchanged: there was still a posthrough Quandl, for historical price data, and data itive average daily rate-of-change in the price of Bitcoin, recorded on Bitcointalk.org as a source for security and the effect of a security breach in the previous week breaches. This is the best data source about Bitcoin se- still was not statistically significant. curity breaches that is available, although it is still im- Discussion perfect (it becomes spotty after March 2014 and stops It is clear, then, that hacks, scams, and other altogether after November 2014). Using the Bitcointalk security breaches do not have an effect on the price of data, I coded a binary dummy variable to record wheth- Bitcoin. This has many possible causes and important er a security breach had occurred on that day of trad- implications for the future of Bitcoin as an asset. The ing,9 as well as a variable for daily rate of change in the most important possible reason that the price of Bitprice of Bitcoin, because none was recorded in the orig- coin is relatively unresponsive to security breaches is inal USD-BTC exchange rate data from Quandl. This because security concerns are “priced-in.” One of the variable effectively captures the daily rate of return (in fundamental assumptions of the Efficient-Market HyUSD) on holding Bitcoin because it reflects the day-to- pothesis is that asset prices reflect all available informaday capital gain of the asset. I created a linear regression tion.10 Asset prices, then, only change in response to model to test whether there is a significant difference new information becoming available to buyers and sellbetween the average daily rate of change of Bitcoin price ers. For the price of Bitcoin to drop in response to secuon days with and without security breaches. The model rity breaches would suggest that these security breaches is expressed as: made new information available to investors. Bitcoin Rate of change in BTC price = β0 + β1 (security breach) + (unexplained error)

investors, both individuals and corporations, are acutely aware of its security troubles,11 and many have taken steps to adopt what are now accepted as best-practic-

9 Coded as 1 if there was a security breach and 0 if there was none.

10 Eugene F. Fama, “Efficient Capital Markets: A Review of Theory and Empirical Work,” The Journal of Finance 25, no. 2 (1970): 383–417, https://doi.org/10.2307/2325486.

11 Mark Frauenfelder, “‘I Forgot My PIN’: An Epic Tale of Losing $30,000 in Bitcoin,” WIRED, October 29, 17

11

es for storing Bitcoin, including using wallets that are not accessible from the internet, Hacks, scams, and other have taken steps to adopt what are now accepted as best-practices for storing Bitcoin, including using wallets that are not accessible from the internet.

Hacks, scams, and other losses, then, do not make any new information available to investors, and therefore do not cause any change in price market-wide. It may, of course, seem a bit incongruous to apply the Efficient Market Hypothesis (EMH), which assumes rational investors, to an asset which some economists have claimed provides evidence against EMH.12 This is not an unreasonable criticism to make, but EMH provides a strong explanation for the Bitcoin exchange rate’s unresponsiveness to security breaches whether or not it provides an explanation for investor decisions to buy Bitcoin in the first place. More research, particularly from a behavioral economics perspective, needs to be done on why investors participate in markets that appear to be asset bubbles, including Bitcoin. This is not to discount the arguments of Bitcoin enthusiasts, but simply to say that more research is necessary on this market and why investors value Bitcoins at the prices they have paid over the past years.

A Tale of Two Hacks

Why, then, if the price of Bitcoin has not responded to security problems, is the assertion so common, even in reputable media outlets,13 that the Mt. Gox hack led to a large and sustained downturn in the USDBTC exchange rate? The most obvious reason is that the collapse of Mt. Gox did, indeed coincide with perhaps the biggest and longest-lasting collapse in the price of Bitcoin. On the other hand, this downturn started long before Mt. Gox filed for bankruptcy in February 2014.

The downturn in the price of Bitcoin, as well as its timing, is apparent in Figure 1.

There was, indeed, a sharp decline in the price of Bitcoin around the time of the Mt. Gox collapse, but this decline started several months before the Mt. Gox breach. Yet there is some reason to believe that the Mt. Gox hack did have a negative effect on the price of Bitcoin by hurting the liquidity of the cryptocurrency, or the ability of Bitcoin investors to buy and sell the asset.

In short, when Mt. Gox collapsed, the market for Bitcoin itself may have collapsed because so many trades were conducted through Mt. Gox and so many investors held assets on the platform. At the time it filed for

12

12 13 14 15

bankruptcy, Mt. Gox was the largest Bitcoin exchange, with 36.4% of the market,14 down from over 50% just a month earlier. Furthermore, the Mt. Gox hack led to the loss of about 850,000 Bitcoins -- about 7% of all those in circulation.15 Mt. Gox was too big to fail in the way that it did without massive repercussions for the Bitcoin market as a whole. Also importantly, Mt. Gox did not repay many of its customers the Bitcoins or traditional currencies that they lost in the initial hack.

On the other hand, Bitcoin has made great strides since 2014. Contrast the Mt. Gox hack with the hack of Bitfinex, which, when it occurred in early August 2016, was frequently compared to the Mt. Gox collapse. These comparisons seem apt, at least on the surface, because they involved large security breached of leading Bitcoin exchanges and because the price of Bitcoin fell sharply in the aftermath of the breach. Yet the differences between Bitfinex and Mt. Gox hacks outweigh the similarities. The USD-BTC exchange rate recovered almost as quickly as it fell, with no long-term downturn like the one that happened around the time that Mt. Gox went bankrupt. Furthermore, Bitfinex, while the largest Bitcoin exchange at the beginning of the month when it was hacked, was certainly not as dominant as Mt. Gox in the lead-up to its bankruptcy. Bitfinex had a smaller share of the overall market, and there were many other Bitcoin exchanges in existence to pick up the slack which was left when it temporarily shut down trading in the wake of the hack. The relative market share of Bitfinex and Mt. Gox before their respective breaches is apparent from the figures in the appendix. Perhaps most importantly of all, Bitfinex, unlike Mt. Gox, repaid in full all funds stolen in the hack, and resumed trading not long after the hack.

Conclusion

To say that the Bitfinex hack led to a lasting downturn in the price of Bitcoin is largely unsubstantiated, as evidenced by Bitcoin’s rapid appreciation starting in early 2017, not long after the hack. And while the collapse of Mt. Gox may very well have contributed to the severity and duration of the downturn that the market for Bitcoin was already experiencing when Mt. Gox filed for bankruptcy, this was as much a problem of the market’s over-reliance on a few exchanges as it was a reaction to the Mt. Gox hack. Yet all this is probably little comfort to those whose Bitcoins were stolen in any of the numerous hacks, scams, or other problems with

John Quiggin, “The Bitcoin Bubble and a Bad Hypothesis,” The National Interest, April 16, 2013 Maxey 2017 “Exchanges Ranking” Bitcoinity.org, accessed December 10, 2017, https://data.bitcoinity.org/markets/rank/all/USD?c=e&t=ae “Mt. Gox Files for Bankruptcy, Hit with Lawsuit,” Reuters, February 28, 2014

Bitcoin’s lack of regulation and vulnerability to hacking. coin is largely unresponsive to security breaches, none Again, security breaches were experienced on about of this is to say that buying Bitcoin is a good financial 4% of days in period for which there is data, a striking decision. Indeed, many of the questions posed by inamount given that Bitcoin vestors are outside the scope was worth comparatively of this research. This research, little during this time -- the however, is paticularly aimed at “Bitcoin hacks overall have not average price during this determining the veracity of the led to price decreases, and an time was $162.26, roughly a oft-cited concern that hacks equivalent of the Mt. Gox hack tenth of what it is today. The like the breach of Mt. Gox today is almost unthinkable.” comparison between Mt. could lead to another sustained Gox and Bitfinex should be bear market for Bitcoin. The heartening in that it shows answer, as can be determined how resistant Bitcoin exchanges and the market as a from the data, is no. Bitcoin hacks overall have not led whole are to hacks of the same magnitude as the Mt. to price decreases, and an equivalent of the Mt. Gox Gox breach, but the continued security breaches show hack today is almost unthinkable: there are many more that there is, indeed, still room for improvement in Bitcoin exchanges today than in 2014, and none with keeping Bitcoin infrastructure safe from hackers. the same, “too big to fail” market share that Mt. Gox had

Despite the risks, it is possible to take precau- even in its final days. Financial journalists and analysts, tions against the possibility of hacks, scams, or other then, should stop citing the Mt. Gox hack as evidence security-related Bitcoin losses. There is general agree- that security breaches could cause the Bitcoin market ment among Bitcoin experts that offline wallets are (al- to crash. If an investor is bearish on Bitcoin, there are though not impervious) much safer than online wallets, plenty of legitimate reasons to be – this research, howand buying Bitcoin-denominated assets, which include ever, suggests that the risk of security breaches affecting many of the scams in the dataset, comes with its own the overall price of Bitcoin should not be among them. risks. And while the data suggests that the price of Bit13

Appendix: Market share of Bitfinex and Mt. Gox before their respective hacks

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Market share data used to create the appendix compiled by bitcoinity.org.

References:

BitStamp, Dec 5, 2017 “BTC/USD on BitStamp,” Quandl https://www. Maxey, Daisy. “Should Individuals Invest in Bitcoin? In a Word, No.” quandl.com/collections/markets/bitcoin-data

Wall Street Journal, October 11, 2017, sec. Markets. https:// Dree12, November 16, 2014, “List of Major Bitcoin Heists, Thefts, www.wsj.com/articles/should-individuals-invest-in-bitcoin-

Hacks, Scams, and Losses” Bitcointalk.org in-a-word-no-1507730402.

Fama, Eugene F. “Efficient Capital Markets: A Review of Theory and Moore, Tyler, and Nicolas Christin. “Beware the Middleman: Empir

Empirical Work.” The Journal of Finance 25, no. 2 (1970):

ical Analysis of Bitcoin-Exchange Risk.” In Internation

383–417. https://doi.org/10.2307/2325486.

al Conference on Financial Cryptography and Data Security, Feder, Amir, Neil Gandal, J. T. Hamrick, and Tyler Moore. “The Impact 25–33. Springer, 2013.

of DDoS and Other Security Shocks on Bitcoin Currency Ex “Mt. Gox Files for Bankruptcy, Hit with Lawsuit.” Reuters, February

changes: Evidence from Mt. Gox.” In 15th Workshop on the 28, 2014. https://www.reuters.com/article/us-bitcoin-mt

Economics of Information Security (WEIS), 2016. gox-bankruptcy/mt-gox-files-for-bankruptcy-protection- Frauenfelder, Mark. “‘I Forgot My PIN’: An Epic Tale of Losing $30,000 in-tokyo-media-idUSBREA1R0FX20140228.

in Bitcoin.” WIRED. Accessed December 11, 2017. https:// Popper, Nathaniel. “Warning Signs About Another Giant Bitcoin www.wired.com/story/i-forgot-my-pin-an-epic-tale-of-los

Exchange.” The New York Times, November 21, 2017, sec. ing-dollar30000-in-bitcoin/

Technology. https://www.nytimes.com/2017/11/21/technol “Exchanges Ranking” Bitcoinity.org, accessed December 10, 2017, ogy/bitcoin-bitfinex-tether.html. https://data.bitcoinity.org/markets/rank/all/USD?c=e&t=ae Quiggin, John. “The Bitcoin Bubble and a Bad Hypothesis.” Text.

“Goldman Says the Bitcoin Haters Just Don’t Get It.” Bloomberg.

The National Interest. Accessed December 11, 2017. http://

Com, November 29, 2017. https://www.bloomberg.com/ nationalinterest.org/commentary/the-bitcoin-bub news/articles/2017-11-29/goldman-s-currie-says-bitcoin-is- ble-bad-hypothesis-8353. a-commodity-much-like-gold.

“The Curious Case of the Missing Mt. Gox Bitcoin Fortune.” Cy “Jamie Dimon Slams Bitcoin as a ‘Fraud.’” Bloomberg.Com, Septem

berscoop (blog), June 21, 2017. https://www.cyberscoop.

ber 12, 2017. https://www.bloomberg.com/news/arti com/bitcoin-mt-gox-chainalysis-elliptic/. cles/2017-09-12/jpmorgan-s-ceo-says-he-d-fire- traders-who-bet-on-fraud-bitcoin.

David Hervey is a Senior in Emory College, studying Political Science and Economics. He is originally from San Diego, California. His research interests include insurgency conflicts, political philosophy, and ancient history, in addition to finance.

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Gendered Patterns of Mental Health Attribution: An investigation into accounts of women’s stress in Léogâne, Haiti

Diana Cagliero

Wikimedia Commons

Abstract

discussion because male authority is widely acknowl This qualitative study explored the causes of edged in these communities. In order for an intervenwomen’s stress in the community of Léogâne, Haiti. tion to benefit women, it would be important to underMale and female participants (n=28) were interviewed stand the perspective of both members of a family unit. to assess the experiences of Haitian women and the Generally, “women are responsible for market transacimpact gender roles have on their mental health. In tions, management of the family budget, food preparathese in-depth interviews, male participants referred to tion, and care of the children” while men are “responsiwomen’s stresses as somatic diseases. In these cases, the ble for agricultural work, providing for the family, and repair and maintenance of men would describe the home.” (World Health the effects of stress on Organization, 2010, p. 5). women as resulting in “As a nation with poor healthcare Overall, understanding all diseases like high blood allocation, the [Haitian] government the factors that are used pressure or AIDS, or does not prioritize mental health.” to describe and discuss describe it through stress for Haitian women symptoms such as by both male and female weight loss or high participants will be key to designing a mental health inblood pressure. While female participants also used some language of psychological distress and somatiza- tervention in the future. tion of symptoms, the stress was mainly referred to in terms of their ability to complete domestic tasks, obtain Methods economic well-being, and maintain their family. Wom An eight-week study on reproductive and menen would describe stress as resulting in their inability tal health interventions and strategies was conducted in to complete daily domestic tasks such as doing laundry Léogâne, Haiti by a group of students from both Emoor caring for children. Understanding and recognizing ry University and Duke University from June to July of these gendered interpretations of women’s stress may 2017. allow for greater clinical recognition of mental health complications and the development of interventions.

Introduction

Mental health is a serious problem in low resource countries such as Haiti. As “mental health… has not been a priority for the [Haitian] government. In the absence of a mental health policy, there has been no real planning of services. The mental health system has very few professionals.” (World Health Organization, 2010, p. 18). As a nation with poor healthcare allocation, the government does not prioritize mental health. Furthermore, mental illness holds a stigma, especially in regard to types of healthcare, as “etiologic beliefs may lead the mentally ill away from doctors and towards those better able to ‘manipulate the spirit’” (Farmer, 1992, p. 267).

A combination of cultural and resource-limiting factors has led to few mental health treatment options for the majority of the population.

Very few studies have addressed mental health problems resulting from gendered interpretations and roles for Haitian women. In a country with defined roles between couples, it is important to understand the gendered way of speaking about the stressed of women in the community. Male participants were included in the 18

Figure 1: Map of Haiti showing Léogâne.

Research was facilitated by an NGO that ran a birthing clinic in the region. Translators who spoke both English and Creole worked with the group of students to conduct qualitative interviews within the community. The set of interview questions were translated into Creole and were reviewed by the translators before beginning the interviews to ensure clarity and understanding.

Wikimedia Commons

Twenty-eight semi-structured interviews were conducted with members of the community, both community leaders and laypersons. Interviews were conducted with both male and female participants, with at least one translator and two student researchers present. Interviews ranged from fifteen minutes to over an hour. Interviews included questions focusing on decision-making within the household, community support, and other themes centering on women’s stressors.

The translators and the students transcribed audio recordings into English, and notes from observations made in the interviews were included in the transcripts. The research team developed a codebook including themes such as the value of women, recognizing stress, and decision-making among others. Members of the team coded transcripts after establishing inter-coder reliability. The program MaxQDA was used for coding and analysis. The code for recognizing stress was extracted from the program and contrasted using gender as a variable for this analysis.

Results

Overview of Recognizing Stress

32 instances of recognizing stress were identified in the interview transcripts. Recognizing stress was discussed in regard to recognizing stress in others and also in terms of the causes of stress. Participants discussed recognizing stress in themselves and in others through illness, behavioral changes, or in regard to the

cause of the stress that they encounter on a regular basis. Participants mentioned somatic symptoms such as high blood sugar, weight gain or loss, and hypertension as a way to detect stress in others. The direct cause was also a way of communicating stress in the interview and included domestic and economic challenges.

Male Perceptions of Women’s Stress

The main way in which men recognized stress in women was through physical changes in the women, citing illnesses such as diabetes or AIDS, or symptomologies such as weight loss and high blood pressure.

“It can make you lose weight. And it can waste some of the time that you have in life. That makes you late in your life...Because when you have to move and you can’t finally lose hope,...

The stress lives in you and makes you lose hope.”

Male, early 20s “It can increase your blood pressure, thinking too much can give that to you. Someone who doesn’t have another illness, thinking too much can give it to you.” Male, 21 “The stress can give the person a lot of problems.

It means that the stress can cause the person to have diabetes - the stress can cause the person to have sugar.” Male, 40, businessman “Firstly, it can make the women or the men 19

crazy. And a big person might turn skinny. All those things are from stress.” Male, 44 “What kind of sicknesses can this stress cause?

Participant 2: AIDS” Male, early 20s

While male participants occasionally ttalked about the economic hardships that women faced which correlated with stress, the majority of the discourse surrounding stress in Haitian women included using language of somatization.

Female Perceptions of Women’s Stress

While female participants occasionally discussed physical symptoms associated with stress such as headaches, the majority described female stress through domestic problems and responsibilities. This stress is tied to their inability to fulfill social or domestic roles.

but I cannot go. I am thinking about all of this.

My clothes are dirty and I want to wash them but I can’t.” Female, 41, nurse’s assistant “When you are overthinking, it can produce other things in you...Because when you are having a problem you don’t go relaxing, you are sitting and thinking and thinking and thinking, you can feel saturated and you feel like your head might explode. That makes you stressed and you become not well. It creates other...diseases in your body it can give you diabetes or make you have high blood pressure.” Female, 39, nurse

“They sit by themselves, they can’t work, they don’t bathe, they don’t take care of themselves, they beat their children, they have bizarre behavior” Female, 26, nurse “Because sometimes there are women that are stressed, they don’t have the means to help their family to make their home function.” Female, 35, member of women’s group “The child might be naked and they don’t have money to put clothes on him. She becomes neglecting of the child. When it’s time to give a bath to the child, to feed them, she just leaves the child dirty.” Female, 57, nun

FMSC FLICKR

Discussion

Male perspectives on women’s stress included language of somatization of symptoms. Anthropologist Arthur Kleinman studied somatization in China, and “I was working, but because I have a baby, I found that language of somatization was preferred when don’t go to work, I don’t feel like spending all my speaking to medical professionals as mental illness is time sitting here, I’m uneasy because I was not highly stigmatized (Kleinman, 1977, p. 6). Kleinman’s used to sitting in the house, I don’t feel comfortresults showed that “popular labels for mental illness able.” Female, 35, member of women’s group cover only indisputably psychotic behavior and mental retardation” (1977, p. 6). This finding was supported in

Furthermore, women and men spoke of the the interviews conducted in this study, as a major term stress of women in regard to the effects of stress and used for describing women with mental illnesses was overthinking. Thinking too much (or reflechi twop in fou. In fact, a study by Khoury et al. found that “the casCreole) is a local idiom of distress and is commonly es referred to us reflected moderate to severe mental illheard among women especially when describing their ness, often with some component of psychotic features, stress, but was also mentioned with male participants. locally identified as fou (Khoury et al., 2012). Cases of somatization of women’s stress included diseases such “When you are overthinking, you are thinking as AIDS or diabetes, or symptoms such as weight loss or and thinking hmm I am sick and I need to go to high blood pressure. However, the distinction between the hospital but I can’t. I am hungry and I need the terms diseases and illness was seen in the way men to go to the market but I cannot go. I need water 20

spoke of women’s stress. While “disease can be thought is simply stigmatized and is therefore avoided (Kaiser et of as malfunctioning or maladaptation of biological or al., 2015). Unlike other conditions, the stress that results psychological processes”, illness is “the personal, inter- in a woman’s ability to fulfill her social or domestic role personal, and cultural reaction to disease” (Kleinman, does not seem to be legitimized as an illness for which a 1987, p. 9). Somatic diseases sick role was afforded. such as AIDS or diabetes were

Female and male percepalso recognized as illnesses in tions of women’s stress were “Female perceptions of these discussions, while menalso frequently tied to the term women’s stress are closely tal illnesses did not hold the “reflechi twop” or “thinking too same status. While women much,” a local idiom of distress. tied to the outcomes of the also occasionally brought up stress; mainly their inability In fact, the DSM-5 includes in these somatic symptoms when its appendix a section on culto fulfill societal roles.” speaking of stress, it was pretural idioms of distress, defindominantly men who discussed ing them as “ways of expressing these with regards to women in distress that may not involve their community. specific symptoms or syndromes, but that provide col Female perceptions of women’s stress are close- lective, shared ways of experiencing and talking about ly tied to the outcomes of the stress; mainly their in- personal or social concerns” (American Psychiatric Asability to fulfill societal roles. Stress is recognized be- sociation, 2013, p. 758). “Thinking too much” is a local cause it can result in women not being able to go about idiom used to describe stress throughout the interviews their daily domestic tasks, most notably childcare. This conducted. However, it does not directly translate to perception is tied to the concept of a sick role, a term any common mental disorders such as anxiety or decoined by sociologist Talcott Parsons. The sick role is pression (Kaiser et al., 2015). Creating this connection a label placed on members of a group who are affected could result in generalizing a “category of distress that by an illness. The sick role uses the resulting disabili- ranges from normative experience to severe forms of ty from this illness to afford legitimacy to a label (Par- suffering” (Kaiser et al., 2015). However, drawing on sons, 1951, p.193). This legitimacy is important because this local idiom of distress in future clinical communithough the member is exempt from their normal social cation or therapeutic interventions could be beneficial role or function in society, they are fine as long as they for stigma reduction of mental illnesses (Kaiser et al., maintain the obligation to seek “technically competent 2015). help” for the illness, which varies among cultures (Parsons, 1951, p. 294). The sick role is not applicable to Conclusion Mental illness stigma is tied to the gendered lanwomen suffering from stress in these interviews, as the stress results in their inability to fulfill their roles as eco- guage of somatization and the lack of a sick role for men nomic providers or childcare, but there is no claim to and women, respectively. Understanding and recognizlegitimacy for this condition. Therefore, when women ing these gendered interpretations of women’s stress see themselves and others suffering from this stress, it is along with implementing local idioms of distress may a failure and not an illness recognized and legitimized allow for greater clinical recognition of mental health by their peers. The circumstances behind this may stem complications and the development of future intervenfrom different sources. A possible hypothesis could be tions to reduce women’s stress. that the task of child rearing is seen as a critical part of being a woman, not just a role that is assigned to an individual. According to many, motherhood is viewed Acknowledgements This research would not have been possible as a crucial part of womanhood around the world and is evidenced by the phrase “there are no sick days when without the support of Family Health Ministries, Emyou’re a mom” which is frequently a coined term in the ory Global Health Institute, Bonnie Kaiser of Emory US. Another hypothesis for why the sick role doesn’t University and Duke Global Health Institute and the seem to apply to women in this community is the lack community of Léogâne, Haiti. I would also like to thank of legitimacy for mental health challenges in their soci- my faculty mentor, Dr. Peter Brown. ety. Mental health care may be seen as unnecessary or

21

References:

Psychiatric Treatment in Rural Haiti? Culture Medicine

and Psychiatry, 36(3), 514-534. doi:10.1007/s11013-012- American Psychiatric Association. (2013). Diagnostic and 9270-2

statistical manual of mental disorders (5th ed.). Arlington, Kleinman, A. M. (1977). DEPRESSION, SOMATIZATION AND

VA: American Psychiatric Publishing.

THE “NEW CROSS CULTURAL PSYCHIATRY”. Social Farmer, P. (1992). The birth of the Klinik: A cultural history of

Science & Medicine, 11(1), 3-10.

Haitian professional psychiatry. Ethnopsychiatry: The Kleinman, A. (1987). Anthropology and Psychiatry - the Role of

cultural construction of professional and folk psychiatries,

Culture in Cross-Cultural Research on Illness. British

ed. Pp. 251-272. Albany: SUNY.

Journal of Psychiatry, 151, 447-454. doi:10.1192/ Kaiser, B. N., Haroz, E. E., Kohrt, B. A., Bolton, P. A., Bass, J. K., & bjp.151.4.447

Hinton, D. E. (2015). “Thinking too much”: A systematic Parsons, T. (1951). The Social System(2nd ed.). London: Routledge.

review of a common idiom of distress. Social Science & WHO/PAHO. (2010). Culture et and Mental Health in Haiti: A Medicine, 147,170-183.doi:10.1016/j.socscimed.2015.10.044 Literature Review. Geneva: WHO. Khoury, N. M., Kaiser, B. N., Keys, H. M., Brewster, A. R. T., &

Kohrt, B. A. (2012). Explanatory Models and

Mental Health Treatment: Is Vodou an Obstacle to

Diana Cagliero is a recent Emory graduate as of December 2017. She majored in Anthropology and Human Biology with a minor in Ethics. In her time at Emory she was awarded a grant for a research project through Emory Global Health Institute with a multidisciplinary research team in Léogâne, Haiti in the summer of 2017. In this time they completed a project on stressors and mental health for women in the community under the supervision of Dr. Bonnie Kaiser with support from Dr. Peter Brown in the Anthropology department.

22

Student Spotlight: Latha Karne (19C)

With tens of thousands of Americans dying from opioid overdoses each year, the opioid epidemic is one of the most pressing public health issues of the 21st century. However, efforts to study the biology that underlies this addiction remain limited by challenges in research design related to drug administration, ethical concerns, and an overall lack of adequate tools necessary to identifying molecular mechanisms.

Emory College student Latha Karne (19C) and a team of researchers in the lab of David Weinshenker, Ph.D. are working to address this gap in understanding by optimizing a new system for studying drug addiction.

Currently, the standard approach for studying drug addiction in rodent models requires that a surgically implanted device and single animal housing. The primary limitation of this approach is that it is not translational because humans do not live in social isolation and social environments are often the circumstances that provoke use of drugs like opioids. Using a novel device known as the Intellicage, Karne and Weinshenker aim to develop an approach in which animals treated with addictive substances can be housed in social environments. Karne describes the Intellicage is a “behavioral apparatus that allows for oral drug self-administration in group-housed mice.” In addition to living in a social environment, Karne says this system is unique because it allows for mice to control their own drug administration and is more reflective of human addiction behavior.

The goal of Karne’s project is to optimize a specific parameter of the Intellicage: drug administration.

To do this, opioid morphine is made available to rodents in the cage via bottle that accessed by pressing a lever. However, animals often abstain from drinking morphine solutions in scientific studies due to its extreme bitter taste. Karne aims to mask this taste by mix-

Wolf von Waldow

Figure 1: Example of Intellicage drug administration

ing the drug with a sweeter substance—saccharin. This task is not as simple as it seems; Karne must find the perfect balance between sweetness and bitterness such that the motivation for solution consumption is due to the drug’s addictive properties rather than its alluring taste.

The success of Karne’s project currently relies on whether rodents are motivated to get the drug solution.

Motivation is measured by A) the work exerted and B) the negative consequences endured in order to obtain the goal. For example, if obtaining morphine is associated with an unpleasant air puff towards the rodent, will the animal return to drink the solution? Motivation for the morphine solution is dependent on whether the animal pursues a reward in spite of the work or negative consequences associated with it. Interestingly, Karne says, this paradigm is parallel to real-life scenarios in which individuals with drug addictions continue to administer drugs in spite of its repercussions. In the same way that animals disregard ramifications in light of addiction, humans do too.

All in all, Karne describes her research project as a fun and exciting endeavor. Since starting in the Weinshenker lab the summer after her freshman year at Emory, Karne has earned an independent research grant to fund her project and hopes to one day earn an M.D.-Ph.D. “Know your limits,” she says, “and don’t forget to have fun!”

Written by Natalia Brody

23

SOCIAL CLASS AND SUICIDE: INCOME VERSUS EDUCATION AS MEASURES OF CLASS

Elizabeth Johnson

Pexels

Abstract

26

in order to provide additional evidence on the relationship between suicide and social class, as the picture

The relationship between suicide and social painted by existing literature is complex and often class, especially when measured by education, remains contradictory. unclear in existing literature. The objective of this

The predominant influence on the study of study was to characterize this relationship by using suicide is still Émile Durkheim’s 1897 text, Suicide. both income and years of education to measure social This definitive exploration class. Using data on more investigated the social, rather than 20,013 individuals from than intrapersonal, causes of “Suicide claimed a known the Collaborative Psychiatsuicide. Durkheim identified ric Epidemiology Surveys, total of 44,193 lives in the four types of suicide linked to I found that low-income United States, making it the different types of societies and individuals were more likely tenth leading cause of death circumstances within them (2). to have seriously thought Egoistic suicide is caused by overall and the second for about committing suicide, a lack of integration into the have made a plan to commit individuals aged 15-34” larger society, which makes an suicide, and have attempted individual feel without purpose. suicide than high-income Altruistic suicides are caused individuals. Individuals with low education were more by too much integration into society until the needs of likely to have attempted suicide, but individuals with the group outweigh those of the individual. Anomic 13-15 years of education were most likely to have consuicide occurs in times of social crisis and is caused by sidered it, reflecting a statistically significant trend that a lack of societal restraint and inability for the indiis neither clearly positive nor clearly negative. Neither vidual to achieve their goals. The opposite extreme of income nor education was associated with the age at over-regulation can cause fatalistic suicide. which someone had first considered suicide, and plans

Durkheim conceptualizes suicide as “any case of suicide only related to income, not education. Based of death resulting directly or indirectly from a posion the ideas of Émile Durkheim, education may share tive or negative act, carried out by the victim himself, a unique relationship with suicide because educated which he knows will produce this result” (3). Interestindividuals tend to commit egoistic suicide. These disingly, intent is left out of this equation. In this definiparate results reflect the challenges in operationalizing tion of suicide, throwing oneself in front of a bullet for social class and raise questions about the effectiveness a loved one would be considered suicide, though death of education as an indicator of this concept in studies is not the goal of the action (2). relating to suicide and possibly other mental health

The survey used in this research does not topics. define suicide for the individual being interviewed.

Therefore, in conceptualizing suicide for this study, Introduction it is important to consider what a layperson would

In 2015, the second leading cause of death for define as suicide. Merriam-Webster dictionary defines young people was completely preventable. Suicide “suicide” as “the act or instance of taking one’s own life claimed a known total of 44,193 lives in the United voluntarily and intentionally” (4), indicating that the States, making it the tenth leading cause of death over- intent Durkheim excludes is a component of how most all and the second for individuals aged 15-34 (1). Even people consider suicide. The survey assesses thoughts this staggering number may be lower than the actual of suicide; presumably, the bullet example above would amount of deaths due to the perceived stigma of dying not be premeditated and therefore could not be capof suicide. tured by the survey, while intentional plans of suicide

The prevention of suicide is two-pronged: not could. Therefore, this second definition is more useful only must we seek out effective interventions, but we for the purposes of this study. also must ascertain which individuals are most at risk

Durkheim proposed a hypothetical relationship to become suicidal. Prevention programs matter little between suicide and social class, particularly educaunless effectively applied to the most relevant group. tion (2). Since egoistic suicide relates to isolation and The goal of this paper is to analyze existing survey data the erosion of traditional beliefs, increasing education

should likewise increase the suicide rate. This seems counterintuitive - if increased social class spares an individual from many stresses, strains, and social ills, why does increasing a measure tied to social class make an individual more likely to take their own life?

This apparent contradiction reflects the difficulty in operationalizing this concept.

Multiple theorists have proposed definitions of social class. In the 1848 Communist Manifesto, German theorist Karl Marx divides society into two groups: the bourgeoisie and the proletariat (5). This division is structured by ownership of the means of production. Marx’s ideas remain critical to the study of social class, but they are somewhat limiting; for FLICKR example, while a university president may not own the means of production, she likely has little in common to kill themselves, and played a role in mediating the with the blue-collar factory workers who also would be influence of other class indicators in alcohol-assisted grouped into the proletariat. suicides. A study on Finnish women using data taken

Subsequent theorists have expanded Marx’s from the same time period found the same overall binary to be more encompassing. Perhaps the aforeresults, though education did not mediate the effects of mentioned university president would fit in well with income and employment status in this case (10). Other the professional-managerial class, which controls pro- studies have likewise supported a link between suicide duction processes without owning them (6). Analytical and education in the opposite direction of Durkheim’s Marxist Erik Olin Wright later further expanded social prediction (11). class with an elaborated class typology incorporating

However, some studies do support a positive relation to the means of production, authority, and correlation between education and suicide, even when scarce skills, and number of employees (7). not true of other measures of social class. While Reck These expanded classification systems still er and Moore (12) found that other measures of social hinge on economic class, including unempower and access to ployment and poverty, means of production “A Swedish study found that indilinked lower class with as defining social class. greater suicide levels, viduals in the process of obtaining a However, income is education was differuniversity degree were twice as likely not the only indicaent. Higher education to commit suicide as individuals who tor of social class; for levels in a county were example, a millionaire had already attained a degree” correlated with an inmay choose to live a creased risk of suicide modest life. Sociologist in the same county.

Max Weber recognized While this study used counties as a unit of analysis, that consumption patterns are useful in defining social Pompii et al. (13) found that individuals with greater class (8). His broader definition of class incorporates educational attainment were significantly more likely life chances, economic resources, and labor conditions. to complete suicide.

The concept of life chances includes access to resources Some studies portray a more complicated such as education, the other measure of social class relationship between suicide and education. In schizoused in the present study. phrenia patients, low levels of education are associated

Maki and Martikainen’s 2008 study of Finnish with a high risk of suicide, and the same is true for men (9) found that low social class was associated with high levels of education (14). Thus, the risk of suicide increased risk of both alcohol-assisted and non-alcohol relative to education cannot be adequately portrayed assisted suicide. Education was inversely related to sui- in terms of only positive or negative, but is better cide, meaning that less educated men were more likely expressed by a curvilinear, U-shaped relationship. This

27

relationship was mathematically demonstrated in the overall population and in both sexes by researchers in the UK using the Education Index as a proxy for educational attainment (15). A Swedish study found that individuals in the process of obtaining a university degree were twice as likely to commit suicide as individuals who had already attained a degree (16).

The purpose of the present study is to better characterize the relationship between social class and suicide. Education and income will be analyzed as measures of social class, and four measures of suicidality from the survey will be considered. The hypotheses are as follows: H1: Persons with more years of education are more likely to have considered suicide, to have considered it at a younger age, to have made a plan for committing suicide, and to have attempted suicide.

H2: Persons with lower income are more likely to have considered suicide, to have considered it at a younger age, to have made a plan for committing suicide, and to have attempted suicide.

Methods

This research used the CPES, the Collaborative Psychiatric Epidemiology Surveys. The objectives of the CPES are to collect data on mental disorders, related impairments, and treatments and to assess the relationship between mental health and social and cultural issues. These data were collected between the years 2001 and 2003. A total of 20,013 surveys were completed from a total of 27,835 eligible households or individuals. This gives the CPES a response rate of approximately 72%.

Using survey data is appropriate for this study because it allows the inclusion of large numbers of individuals, and standardized questions ensure that the necessary information is obtained. A weakness of this methodology is that the gathered information lacks depth - while it may describe the relationship between suicide and class, individuals are unable to explain why their thoughts of suicide occurred and how this relates to their social class, as they might in personal interviews.

Data were statistically analyzed using Stata.

Income was recoded for the purposes of this analysis 28

into three categories (low-income, middle-income, and high-income) based on findings from the Pew Research Center, which defines the middle class as having two-thirds to double the median household income in the U.S. (17). As such, low-income was defined as less than $42,000 in annual household income, high-income as more than $125,000 in annual household income, and the middle class in between. Education was recoded from four categories to three (12 or fewer years of education, 13-15 years, and 16+ years). Age was split into three categories, minor (younger than 18, the legal age of majority in the U.S.), young adult (1829), and adult (30+).

This study fills a gap in the current literature due to its use of measures other than death certificates or death statistics as a way of assessing an individual’s tendency towards suicide. These methods, which were commonly utilized in prior research, may not accurately capture the full portrait of all of the steps leading to a suicide. If something in the intermediate stages between considering suicide and committing it exacerbates which demographics are most susceptible, questioning the living could lead to novel results not found by assessing the dead.

Results and Discussion

Questions concerning educational level and income were answered by 20,013 respondents. Because only individuals who answered “yes� when asked whether or not they had ever seriously considered committing suicide were asked further questions about suicidality, these questions had only 2,046 respondents.

The results of this study partially support the hypotheses. Three of the four tested measures of suicidality showed statistically significant relationships with income, supporting the hypothesis that persons with lower income show a greater tendency towards suicide. Low-income individuals were more likely to think seriously about committing suicide (p=0.000) (Table 2), make a plan to commit suicide (p=0.000), and attempt suicide (p=0.000) than were high-income individuals. However, there was not a statistically significant relationship between the age at which an individual first considered suicide and their income (p=0.513).

Low-income individuals were over twice as likely to have seriously thought about committing suicide than high-income individuals (16.40% vs. only 6.12%) (Table 2). They were also much more likely to have made a plan to commit suicide than high-income

Table 2: Suicidality by Income Suicidality

Lower-income Middle-income (n=9,097) (n=5,914)

High-income P-Value* (n=5,002)

%

%

%

Seriously thought about committing suicide (missing=4,123)

0.000

No

83.60

85.69

93.88

Yes

16.40

14.31

6.12

Age first seriously thought about committing suicide (missing=17,922)

0.513

Minor (<=17)

40.98

43.11

36.55

Young Adult (18-29)

34.50

33.23

36.95

Adult (>=30)

24.62

23.65

26.51

Made plan for committing suicide (missing=17,922)

0.000

No

62.44

66.17

76.71

Yes

37.56

33.83

23.29

Ever attempted suicide (missing=17,922)

0.000

No

60.65

69.91

83.94

Yes

39.35

30.09

16.06

individuals (37.56% vs. 23.29%) and over twice as

However, the relationship uncovered between likely to have attempted suicide (37.56% vs. 23.29%). seriously considering suicide and education level is not These results fit with previous studies that have found as straightforward. There is a statistically significant a link between lower social class, lower income, and relationship (p=0.031) between these two variables, suicide rates (9, 10, 12). but the direction of this

The relationship berelationship is unclear; inditween education and suicide viduals with 13-15 years of â&#x20AC;&#x153;Low-income individuals is, as prior literature suggests, education were most likely to were over twice as likely to much more complex. There is say that they had considered have seriously thought about committing suicide (14.01%), a clear relationship between suicide attempts but individuals with greater committing suicide than and education level; 37.93% than or equal to 16 years of high-income individualsâ&#x20AC;? of less-educated individuals education were least likely to who had considered suicide say so (12.02%). This complex had actually attempted it, relationship was hinted at in compared to only 22.82% of those with more years of prior studies which found that suicide was either less education (p=0.000) (Table 1). This fits with previous likely for less educated people (13) or that a curvilinresearch showing that lower levels of education were ear, U-shaped relationship existed between suicide and correlated with increased suicide (9, 10, 11). education (15).

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Table 1: Suicidality by Years of Education Suicidality

0-12 years 13-15 years Greater than or equal (n=9,993) (n=5,290) to 16 years (n=4,730) %

%

%

Seriously thought about committing suicide (missing=4,123)

0.031

No

86.78

85.99

87.98

Yes

13.22

14.01

12.02

Age first seriously thought about committing suicide (missing=17,922)

0.153

Minor (<=17)

39.98

43.33

42.95

Young Adult (18-29)

34.29

35.00

33.78

Adult (>=30)

26.72

21.67

23.27

Made plan for committing suicide (missing=17,922)

0.775

No

64.85

66.50

64.88

Yes

35.15

33.50

35.12

Ever attempted suicide (missing=17,922)

30

P-Value*

0.000

No

62.07

65.83

77.18

Yes

37.93

34.17

22.82

The relationship demonstrated in this study is more of an inverse U-shape and could perhaps be explained by results from Lageborn, Ljung, Vaez, and Dahlin (16). These researchers found that Swedish students in the process of obtaining a university degree were twice as likely to commit suicide as those who had already graduated. The proportion of individuals who had considered suicide peaked in the 13-15th year of education, the time in which individuals on a standard educational track would be obtaining their college degree. This could explain why thoughts of suicide decreased after the 16-year mark, when many students would have already completed four years of college.

There was no statistically significant relationship between years of education and the age at which an individual had first seriously thought about committing suicide (p=0.153) (Table 1) and whether the individual had made a plan to do so (p=0.775). The

finding that there is a much greater disparity between more and less educated persons when it comes to attempting suicide than seriously thinking about committing suicide is an interesting result only possible due to the use of survey data rather than death certificates.

Low-income individuals were more likely to seriously think about committing suicide, make a plan to commit suicide, and attempt suicide than high-income individuals. Individuals with low education were more likely to attempt suicide, but this relationship was not found for other indicators of suicidality. There is a statistically significant relationship between years of education and whether or not an individual has considered suicide that is not clearly positive or negative.

Finally, planning suicide is related to income but not to education levels, even though these independent variables both attempt to measure social class.

These results, which reveal a very different

FLICKR

relationship between income and suicide than between education and suicide, can be explained by theory. According to Durkheim, educated persons are committing egoistic suicide for completely different reasons than those for which an individual living in poverty might commit suicide. When suicide is separated from the type and motivation and assessed as a whole, conflicting patterns emerge. This issue raises questions about whether education is an effective conceptualization of social class for research on suicide.

Conclusions

The purpose of the present study was to clarify the complex and often contradictory relationship between social class and suicide using two separate measures of class. There is a straightforward relationship between income and suicide, with wealthier individuals showing significantly decreased suicidality in three of the four measures used for the present study. However, the relationship with education, while significant

for two of the four measures of suicidality tested, is less clear. Less educated individuals are more likely to attempt suicide, but they are not the most likely to have seriously thought about committing suicide.

There are limitations associated with this study.

Because it assessed previously collected data, it was not possible to tailor the questions to the goals of this study. Highest degree attained may have more accurately portrayed education level than years of education (18), and asking whether an individualâ&#x20AC;&#x2122;s education was still in progress would have controlled for the effect found by Lageborn et al. (16). However, using existing survey data allowed for this study to analyze a much larger number of individuals than would have been possible if a new survey were created and distributed. This was especially important given that only a fraction of survey participants answered later suicidality questions (as the first suicide question screened out 17,922 individuals).

Both education and income are well-established measures of social class, so the finding that they

31

produce conflicting results merits future research.

Further studies can help determine which measure most accurately represents the concept of social class and whether this apparent paradox extends beyond suicide to other mental health-related questions. While the relationship between education and suicide remains unclear and varies depending on the measure of suicidality assessed, there is a clear relationship between income and suicide for three of the four measures used. This finding bolsters previous literature on income and suicide, and the lack of such clarity for education adds to the growing field of research into this relationship.

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trieved from http://pewrsr.ch/1TbPyAF 5. Marx K., Engels F. (2002). The communist manifesto. Penguin.

18. Mullis, Jeffery. Personal communication. 25 January 2018.

6. Ehrenreich J., Ehrenreich B. (1979). Pat Walker, ed. Between

Labor and Capital (1st ed.). Boston: South End Press.

Acknowledgements

References:

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Elizabeth Johnson is a third-year biology (BA) and sociology double major. She is currently doing research through the Research in Sociology at Emory Program and has served as an Oxford Research Scholar in two academic departments (biology and English). This is her second published paper. She has also enjoyed presenting her work at various Emory symposia and at the American Association for the Advancement of Scienceâ&#x20AC;&#x2122;s 2017 Annual Meeting. In addition to research, she is involved with Theater Emory, Dooleyâ&#x20AC;&#x2122;s Players, and Ad Hoc Productions, and was involved with Theater Oxford and the Oxford Ensemble of Shakespearean Artists previously.

Elizabeth wishes to attend graduate school and conduct research on cross-cultural expressions of mental illness.

33

ENFERMEDAD DE CHAGAS EN BOLIVIA

The sociopolitical and economic forces which shape health and the present challenges of Chagas disease control in Bolivia

Rusha Majumder and Joseph Medeiros

Wikimedia commons

INTRODUCTION

With 1.8 million Bolivians affected and 3.7 million at risk, Bolivia has the highest Chagas incidence rate in the world (MSF). As of 2016, Bolivia had a population of 10.9 million people, meaning that about 20 to 30 percent of Bolivians are affected by Chagas disease. It is astonishing, then, that about 99 percent of Bolivians do not receive treatment for Chagas disease, which commonly turns fatal when left untreated.

Vector control efforts have failed, governmental aid is negligible, and diagnoses and treatment barriers are prominent. Other research papers that focus on Bolivia’s Chagas problem either focus on a specific issue or contain incomplete data. Many of the papers cited in this paper have emphasized that a flaw in their studies revolve around the lack of data and other research related to Bolivia’s Chagas problem. Unlike other papers, the goal of this paper is to give a thorough overview on the different factors that are contributing to Bolivia’s Chagas problem from an economics perspective. This paper will discuss Bolivia’s macroeconomic situation, how the Bolivian government has exacerbated and neglected Chagas disease, and all the diagnoses and treatment barriers that are preventing patients from receiving the care they need.

Explaining Chagas Disease

About 8 million people are infected with Chagas disease in Mexico, Central and Latin America, with about 2 million of these people located in Bolivia1.

Without treatment, the initially nonexistent or mild symptoms of Chagas disease can become fatally damaging to the heart, and less commonly, to the gastrointestinal system and/or the nervous system.

Chagas disease is caused by the parasite Trypanasoma cruzi (T. cruzi), which nests in the burrows and corners of mud and straw homes and bites people at night. These parasites normally become infected with Chagas when they bite an infected person or animal. The infected parasite, then, passes on Chagas disease to other humans or animals that it bites. After an infected T. cruzi bites an individual, it discards feces near the infected area. It is these feces that causes the transmission by passing through the skin or directly entering the blood stream when the bitten individual rubs the infected area, accidentally causing the feces to enter the open wound.

People can contract Chagas disease without vector borne transmission, namely through congenital, 36

foodborne, organ transplant, or blood transmission.

Chagas disease is not contagious and can be treated and cured with benznidazole and nifurtimox, both of which are almost 100 percent effective in curing the disease if given shortly after transmission (WHO).

Effectiveness of the medicines diminish the longer an infected person waits to start treatment (WHO).

There are two significant phases of Chagas disease. The first is the acute phase, which occurs shortly after transmission and can last for a couple of days to several months. This phase is symptomless in 95 percent of cases. When there are symptoms, the symptoms include fever, rash, fatigue, diarrhea, vomiting, and headaches among others. These symptoms are present in many illnesses or can be short-term effects of irritations that can occur in people’s daily lives (stress, eating spicy food, etc.). Thus, if symptoms occur in the acute phase, they are usually ignored or unnoticed by affected individuals.

After the acute phase is over, there is typically a ten to fifteen-year intermediate stage where no symptoms occur, but the disease progresses. After this stage, the chronic phase occurs, which is quite severe. Many patients incur gastrointestinal and cardiac problems.

Cardiac problems largely consist of congenital heart disease, specifically resulting in cardiomyopathy and heart failure. About 20 to 30 percent of people who are infected with Chagas develop the chronic phase of the disease and require intensive treatment and care to control symptoms. In many cases, a heart transplant or pacemaker is required to save someone who has developed this phase of the disease. Since the chronic phase of Chagas disease contains symptoms that are obvious or life-threatening, this is the phase in which affected individuals search for care. Unfortunately, the cost of treatment in this phase is incredibly high as this paper will further discuss.

SOCIAL, ECONOMIC, AND POLITICAL FORCES THAT SHAPE HEALTH IN BOLIVIA

In a resource-deprived state such as Bolivia, sociopolitical and economic factors influence at once the prevalence of Chagas disease and the delivery of health services that address it. And so this section first gives a concise overview of Bolivia’s sociopolitical history, beginning with the 1952 Revolution and concluding with the country’s current social and political environments (see the Appendix for a more detailed exposition). A discussion of Bolivia’s economy and its implications for health follows the aforementioned conspectus.

 The following section is based on Center for Disease Control (CDC) published content.

Determinants of Sociopolitical Instability

Bolivia’s Economy and its Implications for Health

Bolivia stands out from the rest of South America in terms of diversity, with its ethnic majority constituting the largest proportion of indigenous peoples in the region. In fact, between 44 and 62 percent of Bolivians have indigenous ancestry, while the remainder of the population is either mestizo or of European descent (Watson; “South America”). Bolivia, too, is distinct with regard to its revolutionary history. The Bolivian National Revolution of 1952 is one of only two democratic revolutions that has transpired in the Americas, excluding the War of Independence fought between the self-proclaimed United States and Great Britain (Quijano 572). Thereafter, the country has been afflicted by acute political instability—its governing ideology oscillating between populist and anti-populist poles—rooted in profoundly differential socioeconomic conditions, which reflect Bolivia’s underlying ethnic divide (Sachs and Morales 3).

Within this ethnically cleaved society, the minority has created a culture of discord through its historical domination of Bolivia’s indigenous majority.

Neoliberal economic reforms beginning in the 1980s, such as those obligated by the IMF and the World Bank, mobilized indigenous leaders’ frustrations with the central government given “the persistence of colonial-era class relations and encroachment on indigenous lands,” which contradict its ostensible commitment to a multi-ethnic Bolivia (Healey 85).

They, too, have come to define the past three decades of economic policy. A decade later, further neoliberal reform served as a convenient moment for the Sánchez de Lozada administration to assuage festering indigenous resentment toward the central government. This president, for instance, sought to administer autonomy by integrating provisions for indigenous land rights and recognition into additional neoliberal economic reforms in 1994; without presenting any meaningful challenge to capitalism, this undertaking was feasible (Postero 22). Concurrently, the most pivotal structural shift in modern Bolivian history was effected via 1994 legislation— decentralization, indeed, served to empower the indigenous political movement (Healey 84).

It was precisely this political traction that ultimately allowed the Movement for Socialism, an offshoot of campesino organizations, to facilitate the election of Evo Morales in 2006.

Chagas disease, Schofield and Dias note, has the most significant economic burden of any parasitic disease affecting the Americas (1). More specifically, Chagas disease results in more years of productive life lost than those caused by all other parasitic infections combined (Forsyth 2). Estimates of the annual disease burden on Bolivia range from US$120 to $255 million, figures including treatment costs and the value of productive years lost (Guillen et al. 1; Bono 2). Synthesizing the inextricably linked political and economic dimensions of Bolivia’s Chagas problem is fundamental to fully understanding it. Having considered the former, let us turn to the latter, highlighting the constraints on long-term economic growth and stability.

Since the colonial period, mining has been the vital center of Bolivia’s economy2; first it was silver and then tin in the 20th century (7). There are, of course, inevitable constraints on economic growth imparted by the country’s dependence on mining and, more significantly, its geography: a landlocked nation some 14,000 feet above sea level, which is expansive and sparsely populated (7). Historically, the most economically vibrant region of Bolivia has been the Andean highlands in which the bulk of mining operations have taken place; however, the decline of the mining sector has led to an eastward shift in economic activity toward petroleum products and commercial agriculture (7). Tin and petroleum products accounted for the majority of Bolivia’s accounted exports from the 1960s through the 1980s—coca is an unaccounted export of high economic significance, too (8).

Owing to the 1952 Bolivian Revolution, an economic system of “state capitalism” was instituted, placing the public sector in charge of accumulating capital (Sachs and Morales 11). And despite great variability in the ideology of administrations following the revolution, two economic themes consistently reappear. First, the state was understood to be the chief agent of facilitating economic development (Sachs and Morales 14). Second, the central government proved to be incompetent at fulfilling its ordained economic duty (Sachs and Morales 14). It, too, is highly important to note the impact that the oscillation in policy has had on private sector investment. Given that investors’ perceived policy uncertainty is negatively correlated with levels of private investment, investment in Bolivia has been highly volatile (Stasavage 17). Figure 1 illustrates this fact, plotting the year-on-year percent change in

2, 3 This paragraph is based on Sachs and Morales.

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Figure 1: Annual % growth in fixed capital formation in Bolivia and in Latin America Source: “Gross Fixed Capital Formation (Annual % Growth).” The World Bank, data.worldbank. org/indicator/NE.GDI.FTOT. KD.ZG?locations=BO-ZJ.

Figure 2: Inflation, consumer prices (annual %) Source: “Inflation, consumer prices (annual %).” The World Bank, data.worldbank.org/indicator/ FP.CPI.TOTL.ZG?end=1988&locations=BO&start=1979&view=chart

Figure 3: Health expenditure, total (% of GDP) in Bolivia, Costa Rica, and Uruguay Source: “Health expenditure, total (% of GDP).” The World Bank, data.worldbank.org/indicator/ SH.XPD.TOTL.ZS?view=chart

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real investment in Bolivia in addition to that of Latin America as a whole. With the state occupying such a central economic position, political corruption ensued, as governments would leverage sovereignty for personal or political gain (Sachs and Morales 16). There are three major barriers, Sachs and Morales postulate, to economic stability and long-run growth: income distribution, ideology, and geographical dispersion.

Ultimately, the conventional vision of achieving stable long-run economic growth via the central government, pursuant to the aim of mitigating income inequality, “collapsed in a mass of inconsistencies over the thirty years between the revolution and the onset of the Bolivian hyperinflation” (Sachs and Morales14).

A sequence of external shocks3, Sachs and Morales explain, involving the global rise in interest rates and reduced or nonexistent lending from international capital markets pushed Bolivia, akin to the fate of its neighbors, into recession; however, the political conflicts that plague the country exacerbated the economic contraction, which resulted in hyperinflation and, as such, a comparatively more severe recession (1). After a period of chaos, the Paz Estenssoro administration finally implemented the “New Economic Policy” that realized a break in rampant hyperinflation just a week after its inception, officially ending it in September 1985 (29, 32).

Figure 2 illustrates the dramatic hyperinflation induced by the weak and ill-advised central government’s aggravation of the global recession, with inflation rates just under 12,000 percent at the nadir of the economic crisis. What is rather illuminative is how each president from the 1970s until the Paz Estenssoro administration failed to tackle the severe fundamental economic issues which handicapped the country (20).

Curiously enough, Bolivia entered a period of relative stability in the years after the resolution of hyperinflation in 1985. And throughout Evo Morales’ tenure, Bolivia has seen its best and most balanced GDP growth of the past thirty years, as the government has been able to combat a number of shocks via expansionary fiscal policy (Weisbrot et al. 30).

In addition to the substantial economic growth that has materialized since Morales’ election, government revenue has soared by about 20% of GDP, international reserves have increased from US$1.8 billion in 2006 to US$8.5 billion in 2009, and public investment had risen by about 4% as of 2010 (Weisbrot et al. 3, 14, 20).

Nevertheless, Bolivia is still overwhelmed by an extreme level of poverty that has dire consequences for health outcomes. In fact, Bolivia ranks 113th globally in terms of the GINI equality index, below Algeria and Botswana (“Human Development Reports”). A comparison corresponding to the Morales years between Bolivia and the two Latin American countries most analogous in terms of GDP, which are Uruguay and Costa Rica, reveals that health expenditure as a percentage of GDP is still relatively low in the former. In a confounding manner, Bolivian health expenditure as a percentage of GDP—despite its recent economic prosperity—has consistently been roughly half that of Costa Rica from 2004 to 2014 (see figure 3). The country’s recent economic growth, then, is overshadowed by its persistent inequality and inadequate expenditure on healthcare. And yet the Morales government is professedly devoted to mitigating income inequality and conceiving a universal health system. The recurring theme of contradiction surfaces in the case of Chagas disease control initiatives, too. For example, the MSF Program Manager for Bolivia suggested that government’s current engagement in Chagas disease management is scanty, or perhaps modest at best: “Now it is the turn of Bolivian health authorities, who need to address the need to place Chagas disease in the centre of the public health agenda as a matter of priority.

It is essential that each of these departments have more trained staff who know how to respond accordingly to the control and management requirements of the disease, with a budget adapted according to the number of people living with the disease.” (Bosch) The insufficiency of health expenditure is perhaps most palpable in these statistics: there are only 12 health workers, and only a meager 4.9 doctors, per 10,000 people in Bolivia (“Country Report”; Pérez).

In sum, Bolivia falls far short of where it ought to be in terms of health expenditure—a particularly unpropitious actuality, which is disconcerting due to the Morales administration’s vision of universal healthcare.

39

CONSTRAINTS ON CHAGAS DISEASE CONTROL PROGRAMS

Bolivia’s Health System: Development, Current State of Play, and Limitations

i. Development and Implications of a weak Political Framework

Historically politicized, Bolivia’s public sector is constantly stymied by the nation’s chronic political instability. More specifically, since public sector employees at practically all levels of government are appointed, political change necessarily implies a subsequent large-scale removal and replacement of officials, stifling any intention of providing a “stable civil service” (Prud’ homme et al. 6). The volatility ingrained in the operation of the public sector is reflected in Bolivia’s health system as, even as recently as in the past few years, there has been little consensus of and hence great fluctuation in protocols of addressing key health priorities. The Chagas National Program (ChNP), for example, lacked a codified system for the diagnosis and treatment of the disease for which it was conceived to manage as recently as 2009 (Pinazo et al. 2). Since Ministry of Health data are woolly, there is no published figure for total national expenditure on Chagas disease control. That said, a WHO report estimated that expenditure on endemic diseases was and would be around 2% of aggregate health spending from 1999 to 2002 (Newman et al. 130). Indeed, Bolivia’s health system has been markedly inconsistent in terms of managerial structure for the past forty years (“Health Services System” 11). This instability is in part responsible for the country’s troubling public health record.

More specifically, the high degree of fragmentation indicative of Bolivia’s health system leads to the duplication of services, wasting exceptionally finite and hence critical resources—the fact that the country has the worst social and health indicators in Latin America is congruous with its pervasive inefficiency (Tejerina et al. 91).

The evolution of the country’s current health system began around 1979, when the government sought to create a health system subsuming the public sector, Social Security, and both the nonprofit and for-profit private sectors (“Health Services System” 11).

The Ministry of Health (MoH) has the role of monitoring, regulating, and executing national policies, positioning it at the head of the system’s public sector element (“Health Services System” 11). Furthermore, there is an institution under the control of the MoH 40

3 This paragraph is based on Alvarez et al.

that addresses the public health system’s financial allocation called Las Cajas de Salud (Prud’ homme et al.

37). The regional level was to be run by “prefectures,” individuals chosen by the President of the Republic who were tasked with human resource management and, per the 1994 Law of Popular Participation, the operational tasks left to municipalities/communes were numerous and multifaceted, not least in relation to delivery of health services (Prud’ homme et al. 18). More specifically, municipal governments are responsible for all public services except for economic development, foreign policy, and the enforcement of constitutional law: the maintenance of physical infrastructure for public services (such as education, healthcare, sports, and communal roads), the collection of local taxes, addressing petitions and social concerns, and rural development (Prud’ homme et al. 19).

The aforementioned legislation officially designated Primary Health Care (PHC) development as a national priority, a directive which was fortified just one year later by Ley de Decentralización Administrativa (No. 1654); the latter was designed to improve the quality, efficiency, and accessibility of health services by decentralizing human resources to the country’s nine departments and granting municipalities more autonomy in the delivery of health services (Alvarez et al. 115). As described at the Alma-Ata Declaration in 1978, PHC is “essential healthcare based on practical, scientifically sound, and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination” (“Declaration of Alma-Ata”). One of the most formidable challenges that health reformers inevitably confront is the diversity of Bolivia’s population, necessitating a heterogeneous approach to reform; the country is home to “37 recognized indigenous ethnic groups representing over 60% of the population, reflected in the recently adopted epithet of ‘pluri-national’” (Alvarez et al. 115).

Kinman’s study of health service equity in Bolivia led to a potentially instructive conclusion: that the intercultural initiatives embraced by the United Family Community and Intercultural Health System (SAFCI), such as languages spoken at health centers, might lead to improved access3 (118). This conclusion, Alvarez et al. posit, might fail to be a model of augmenting the accessibility of health services, because the

Schematic 1: The Decentralized Levels, Financing, Provision/Delivery, and Outcomes of the Bolivian Health System Source for data: Fuentes.

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study preceded the recent massive sociopolitical shift (118). To extend the ideas presented in the Appendix, note that this recent reversal of social and political capital, which manifested in the creation and writing of a new Bolivian constitution, fits into the phenomenon that Couso refers to as the “New Latin American” (20). The increase in discourse concerning indigenous citizenship leading to a paradigm shift, of course, is a reflection of the greater integration of the marginalized majority into Bolivian society. Alvarez et al. present the counterpoint to Kinman’s assertion of a positive relationship between languages spoken and health services utilization, suggesting that in light of the recent sociopolitical shift, this relationship may no longer hold due to changes in the general perception of health services (118).

It is also worth noting that, according to Alvarez et al., a large portion of the existing literature on Bolivia’s Chagas problem as of 2015 does not accurately reflect the current state of the situation, because “much of the research is outdated, the quality of studies needs improvement and essential topics such as national health legislation have been largely ignored” (126). That said, the general operational structure initiated by decentralization efforts has remained largely intact for the past decade (see schematic 1).

The National Assembly of Health still develops health policies, which are then undertaken by the Ministry of Health, and each of Bolivia’s nine departments contains its own assembly of health that designs regional health networks (Alvarez et al. 115). And Bolivia’s 339 municipalities each contain a Municipal Health Board that facilitates the delivery of health services given its particular health infrastructure (Alvarez et al. 115). The current system also leverages the positive correlation between social mobilization in addition to community engagement and acceptability of health services through its local health committees, which exist as spaces in which people are free to get involved with the management of health resources; a much more human, and thus much less central and homogenous, approach to altering inhibitive attitudes toward health care (Alvarez et al. 115). In other words, local health committees serve as mechanisms that reduce the demand-side effect occurring when a farmer living in a rural commune, for instance, sees little benefit in health consultation (Prud’ homme et al. 37).

The platform currently shaping health reform, which is being pursued by the MoH, combines the systematic methodology of the SACFI model and the

commitment to the provision of PHC established via Law 475, buttressing the current leadership’s vision of instituting universal coverage aimed at an eventual national single payer system (Alvarez et al. 115). Given the MoH’s relatively recent commitment to a model of PHC that emphasizes community participation, intersectorality, interculturality, and integrality, an emphasis underpinning the government’s current path toward a single payer system, Bolivia’s health system is at the threshold of a new era. And yet, the current system, one of far fewer institutional promises than the one being forged, has failed to address the overwhelming challenge that Chagas disease is for Bolivia—it remains the country with the highest prevalence of the disease (Rendell et al. 2).

Alvarez et al. note that despite the health system’s evident need for improvement in terms of the provision and delivery of health services, many have praised the current Bolivian leadership for sculpting the perception of health into a human right that is central to the social welfare and development of a nation (Alvarez et al. 125). Furthermore, a review of the literature reveals that the country’s impotent and chronically unstable political framework leaches into the operational capacity of the health system, one which is blighted by “tremendous fragmentation and a clear lack of coordination within and among the three subsectors” (“Health Services System” 18). In this way, the flaws of the Bolivian political framework contribute to vital issues of the health system, including the lack of comprehensive policy for the provision and subsequent delivery of the health services fundamental to new health initiatives (Alvarez et al. 125). That is to say: Bolivia must resolve underlying political and institutional deficiencies, if it is to effect constructive reform.

A brief comparison of two of the most decentralized health systems in Latin America, those of Bolivia and Chile, elucidates the relative inefficacy of the former. In Chile, as a result of the central government’s capacity to dictate and enforce basic, pragmatic regulations that inhibit irresponsible municipal behavior, local governments were, in fact, unable to incur a deficit, and they also accumulated locally generated resources to augment central government funding (Bossert et al. 91). Whereas in Bolivia, the central government failed to impose these basic constraints, lacking the institutional capacity displayed by the Chilean central government, and, as such, it unwittingly facilitated a financial crisis for health care (Bossert et al. 91).

Where government investment in and financing for health services are concerned, the narrative of Bolivia is similarly disheartening: total health expenditures as a percent of GDP had a downward trend (2002-2012), falling an absolute 1.65%, despite a concurrent 3% increase in per capita GDP (Alvarez et al. 125). The rate at which resources are being allocated toward the improvement of health services, then, is not only lagging behind the rate of economic growth but is also falling independently.

Bolivia’s well-understood institutional incompetence and plainly inadequate investment in its confrontation of pressing public health issues, even those tantamount to Chagas disease, is echoed in the response of international humanitarian groups that are intimately familiar with the country and its problems, such as Doctors Without Borders: “ . . . despite the existence of Law 3374 since 2006, which declares Chagas disease a national priority for all provinces in the country, no regulations have been created to date to allow further progress in access to treatment for the entire population, including those with congenital Chagas or in managing complications of this disease . . . [given] our experience gained over 18 years of fighting this disease . . . [this medical humanitarian organization] urges the Bolivian government to provide greater access to diagnosis and treatment, and to invest the resources necessary for comprehensive care of Chagas disease.” (“[MSF] Ends Chagas Operations”) To illustrate the impact of the limitations of the Bolivian health system, one might cite its Human Development Index of 0.674 in 2015, which positions the country among the bottom four countries in Latin America with respect to the condition of population (“Human Development Report” 2). Moreover, the country ranked 50th and 310th globally in order of the under-five mortality and maternal mortality rates, which are regularly employed in the evaluation of a population’s overall health—by these metrics, Haiti is the only country in the western hemisphere that consistently exhibits worse national health than Bolivia (Alvarez et al. 115). Basically, what is most disconcerting about the Bolivian health system can be summarized in a recurring theme: fragmentation, segmentation, the absence of coordination, and the country’s irresolute political framework lead to an inefficient allocation of

limited resources, greatly limiting accessibility of care.

It is worth emphasizing the distinction between segmentation and fragmentation to better understand the impact that each has on the Bolivian health system.

A segmented health system, in general, is: “[a] coexistence of subsystems with different modalities of financing, affiliation, and service delivery, each of them ‘specialized’ in different population strata according to their place in the workforce, income level, ability to pay, economic status, and social class” (Levcovitz). In Bolivia, the segmentation of its health system restricts income cross-subsidization by isolating different population strata; relatively high-income individuals in urban areas receive far more resources than low-income individuals who often live in rural areas (Tejerina et al. 93). Thus, it follows that the conspicuously high degree of inequality in the allocation of MoH resources is chiefly an issue of segmentation.

In general, a fragmented health system is one of “many units or entities not integrated into the health services network” (Levcovitz). Such a system cannot pass around resources, empirically discovered knowledge, and institutional information due to the absence of vertical or horizontal coordination. The absence of collaboration between the divorced entities that are subsumed under the Bolivian health system leads to high transaction costs, hampering the standardization and quality of services, cost-effectiveness, and efficient delivery (Tejerina et al. 94).

If it persists, this pattern of fragmentation and segmentation, fueled by and the country’s irresolute political framework, portends continuity of the morality caused by endemic diseases, particularly Chagas. ii. Damaging Impact of U.S. Intervention and Aid

Naturally, the United States’ aid for low-income countries is typically rooted in its own economic interests and foreign policy objectives. Consistent with this self-evident reality, USAID objectives mostly neglected Chagas disease between 1971 and 2010, indicating the relatively low importance of the disease within the broader spectrum of U.S. economic, foreign policy, and political objectives in the region (Tejerina et al. 93).

Bolivia, a nation historically stricken by sociopolitical volatility, has been governed according to several ideologies, some more and some less complementary to the aforementioned US interests (see Appendix).

Between 1971 and 2010, the USA-Bolivia relationship reflected this variable complementarity—aid was generally greater during periods during which the 43

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prevailing leadership was considered an ally. The 1970s was defined by the United States’ perpetual struggle to contain communism. As such was the case, the Banzer government, which was highly involved with and influenced by the U.S., received 92mn in aid in its first year alone (Tejerina et al. 94). Whereas during the Siles Suazo era, USAID discontinued all major health programs given the administration’s left-wing ideology (Tejerina et al. 94). USAID began massive investment in Bolivia’s health system when the Paz Estenssoro government rose to power (Tejerina et al. 94). Recall that this same government employed a monetary policy inspired by Jeffrey Sachs, a Professor of Economics at Harvard, ending the hyperinflation within weeks (see “Economic Context and Implications for Health”; Shirley). In other words, the dramatic increase in U.S. health investment during an era governed by the ideology of “multicultural neoliberalism” illustrates the correlation between ideology and the level of U.S. support.

USAID objectives, in contrast to its variable provision of aid, remained consistent throughout this period, and, more specifically, these objectives might have worked against each other while competing for limited MoH resources (Tejerina et al. 101). The pursuit of these objectives not only failed to effectively mitigate drug-related, political, and economic issues, but it also contributed to the segmentation and fragmentation of the Bolivian health system; one factor that constrained USAID officials’ capacity to implement locally appropriate strategies were directives from US Congress regarding market liberalization (Tejerina et al. 90, 97).

USAID’s Community Child Health Project (CCH) tested decentralization, as it allocated traditionally state-held health responsibilities, such as immunization initiatives, to local governments (Tejerina et al. 95). In 1994, decentralization became a codified state policy, mandating the relegation of many healthcare-related operational tasks to local governments (see Appendix). This decentralization policy, though, was suboptimal given the inability of local governments to aptly manage health services, thus exacerbating fragmentation—to the extent that the MoH, international aid, the department, and the municipality were simultaneously managing the same health center (Tejerina et at. 97). According to Tejerina et al., each organization played a disjunctive role in the management of payments, implementation of health initiatives, human resources, and medical devices (97).

New legislation further decentralized the Bolivian health system by transferring the budget for supplies and investment across all sectors to the control of the country’s 312 municipalities, many of which were established by the same law that assigned them operational responsibility (Bossert et al. 87). It is possible, of course, for decentralization policy to be implemented without granting local governments a degree of autonomy identical, or even similar, to that which the central government had. In other words, there can be variation between decentralization policies in terms of the range of choice that is shifted from central governments to smaller, decentralized units. Irrespective of the range of choice that the central government gave its municipalities in 1994, one which was far from complete, Bossert et al. note that given the Bolivian central government’s relatively weak administrative capacity, auxiliary measures should have been put in place to support the municipalities, which had just been saddled with manifold obligations (91). The Bolivian government did not, however, account for local government’s inexperience with institutional tasks, such as budgeting. In fact, this lack of foresight was precisely what facilitated the aforementioned financial crisis for health care, as Bolivian municipalities reallocated their budgets, shifting resources away from health expenditure and toward other priorities.

Despite the broad inefficacy of the decentralization polices that the Bolivian government implemented from 1994 onward, receiving nothing but approval and support from USAID, there is a good deal of evidence that substantiates the theoretical benefits underpinning initiatives to relegate responsibility to local governments. If afforded a greater range of choice, or “decision space,” Bossert et al. conjecture, local government officials might use their highly specific regional knowledge to pioneer regionally optimal solutions to problems afflicting the health system (92). Bossert et al., however, note that their findings were inconclusive with regard to the evaluation of the effectiveness of decentralization policy in Bolivia (91). Still, there exists evidence of the merits of decentralization policy that demands consideration.

Prompted by the lack of a uniform protocol of diagnosis, treatment, and training, a Spanish international collaboration effort initiated the Bolivian platform for the comprehensive care of Chagas disease; six centers specializing in the treatment of the disease were established in 2009 according to a system of vertical organization dictated by the guidelines of ChNP

(Pinazo et al. 1). A database, standardized forms, systematic treatment convention, and training programs for health professionals, Pinazo et al. explain, were vital to the model’s success (1). In just five years, 26,227 Bolivians were screened according to protocol, 69% of which were then diagnosed with Chagas disease—an extraordinary 8,567 of those diagnosed were provided anti-parasitic treatment, and more than 1,616 health professionals were properly trained (Pinazo et al. 2).

Though the Chagas Platform inspires hope in a country overwhelmed by its seemingly intractable problem in Chagas disease, the model is subject to a few limitations.

Pinazo et al., for instance, cite “human trained resources” and “high staff turnover” as two of the model’s most significant constraints (2). Owing to the assistance of local government, these constraints were locally ameliorated (Pinazo et al. 2). With a coordinated effort involving the Chagas program, local governments, and PHC networks, this model not only proves to be effective in bolstering access to care, but also possesses the potential to be a model by which the MoH forges new initiatives (Pinazo et al. 10). An example of an innovative solution that involved the municipalities is the implementation of community information activities. In light of historical difficulties concerning adherence to the treatment of Chagas disease due to the harsh side effects associated with the available drugs, it was remarkable that the aforementioned community engagement efforts generated “excellent adherence to treatment” (Pinazo et al. 9). In this way, the Bolivian Chagas Platform elucidates the value of a decentralized health system: highly specific regional knowledge can enkindle innovative solutions to micro-level issues, thus improving the system overall. Be that as it may, it is clear that the realization of benefit from decentralizing a health system depend on the institutional capacity of a central government. Bossert et al. posit that implementing decentralization policies might still prove beneficial in the absence of effectual central government, if ancillary efforts are made to support local governments (8). It, too, is important to note that the due preparation of local governments is a critical variable in deciding the effect produced by decentralization (Tejerina et al. 101).

In consideration of these determinants, USAID’s support of the Sánchez de Lozada administration’s implementation of decentralization policy—owing to the nonexistence of ancillary efforts, the Bolivian

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central government’s impotence, and the local governments’ utter lack of experience—inflamed the segmentation and fragmentation of the health system. USAID also contributed to the segmentation of the health system in Bolivia by pursuing the privatization and deregulation of the health sector (Tejerina et al. 96).

Moreover, USAID’s support of projects similar to PROSALUD, which were specifically initiated to address middle class demand for health services, led to the development of subsystems that serve different strata of the population (Tejerina et al. 96). It, too, aggravated the fragmentation of the Bolivian health system by forming and sustaining a horde of specialized NGOs that were not integrated (Tejerina et al. 101). Despite the United States’ annual investment of $18.5mn in Bolivian health programs (from 1996-2008), it failed to achieve its own objectives, while intensifying the underlying problems of the health system in Bolivia and brushing aside the most urgent of the country’s health crises, namely Chagas disease (Tejerina et al. 100).

Inadequate Vector Control Efforts

55 percent of Bolivia’s land is endemic for Chagas even though the Bolivian government spent over US$2 million in 1997, without including aid given by the United Nations, on vector control efforts (what 45

vector control has encompassed will be explained in Gran Chaco need steadfast vector control efforts to further detail later in this paper) (Schofield). The govtruly stop this endemic from spreading. Vector control ernment of Bolivia has spent much less on vector con- in the Gran Chaco consisted of insecticide spraying in trol compared to that of Brazil, households and the killing of any detected which spent almost US$29 milbugs (Gürtler). There are two main types “About 30 percent of lion on vector control, and Argenof vector control: vertical and horizonuntreated infected tina, which spent almost US$13 tal (Vazquez-Procopec)5. Vertical vector individuals, develop million on vector control in 1997 control is when the national government the chronic phase of (Schofield). Though Bolivia has along with government health institutions Chagas, which can be spent less on vector control than implement insecticide spraying strategies. deadly” other countries in Latin America, Horizontal vector control is when commu15 percent of the Gran Chaco, a nities rather than national entities focus on region where vector control efforts have failed, is in these vector control efforts. A study on the cost-effecBolivia, a geographically small nation in comparison tiveness of Argentine vector control strategies showed to Argentina and Brazil. The Gran Chaco is a highly that a mixed strategy is most cost-effective. In Bolivia, endemic area because of its warm, subtropical climate a vertical vector control effort was started in the 1960s, and abundance of trees that attract T. cruzi (Medrabut it then became a horizontal effort in the 2000s.

4 no-Mercado). It is also a highly endemic area because Insecticide spraying required professional spraying its population is sparsely spread and consists of some teams as well as householders to cooperate, while bug of the poorest individuals in Bolivia. These people are detection mainly required householders to kill any T. unable to afford housing that is insufficient for T. cruzi cruzi bugs they spot in their homes. survival and, thus, their adobe and stick houses are

In 1990, there were about 30 million cases of infested with the parasite.

Chagas disease worldwide. Because of vector control

Nevertheless, Chagas disease is becoming an efforts, especially in Latin America, the overall burden increasingly urban illness. Cochabamba is a Bolivian has decreased to about 9 to 11 million people worldcity in which 55 percent of the population originated wide in 2009 (Vazquez-Procopec). The goal of vector from other places and 70 percent of the population control is to reduce infestation to the point where risk were immigrants from rural areas. People immigrated of infection is negligible.6 These efforts have eradiinto Cochabamba among other urban areas because cated T. cruzi in certain places in Argentina, but these they wanted to have better opportunities for themefforts have failed in the Gran Chaco region due to hoselves and their families, but because they came from mogenous insecticide procedures for a heterogeneous Chagas endemic areas, they are causing Chagas to problem, unforeseen genetic variability in the parabecome a more urban illness. More than 80 percent sites, and presence of sylvatic foci in far more places of Chagas cases are due to improper housing and than just the Andean valleys. Sylvatic foci are areas of lack of medical services diagnosing T. cruzi reproduction. infected individuals in rural areas. A The Gran Chaco has study asked child participants under several regions of varied cli“The existing drugs effective in twelve years old to draw the inside of mate, ranging from humid curing T. cruzi infection have not their houses, which are in Cochabamto dry, of varied vegetation, mitigated the Chagas problem, ba, and show where T. cruzi lives in ranging from hardwood which remains the most signifitheir homes. The researchers received forests to swamps, and of cant parasitic disease in the westdrawings of houses where T. cruzi was varied temperatures, rangern hemisphere, with an estimated disease burden 7.5 times larger on walls, on the floor, in nooks and ing from -10 degrees Celthan that of malaria” crannies, and strangely, under beds, sius to 49 degrees Celsius. showcasing the magnitude of vector This regional geographical infestation in these houses. variety shows that different

According to Gürtler, rural areas including the types of insecticide procedures must be implemented

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4 Except where indicated, the following two paragraphs are based on the findings of Medrano-Mercado in Urban Transmission of Chagas Disease in Cochabamba, Bolivia.

5 The remaining paragraph is based on Vazquez-Procopec’s findings in Cost-Effectiveness of Chagas Disease Vector Control Strategies in Northwestern Argentina.

6 Except where indicated, the following seven paragraphs are based on Gürtler’s findings in Sustainability of Vector Control Strategies in the Gran Chaco Region: Current Challenges and Possible Approaches.

according to regional needs. Insecticide procedures include how often spraying is done, where exactly spraying is done, and how long vector control sustainability is continued in a certain area among other factors. Past solutions involved implementing the same insecticide procedure for all areas of the Gran Chaco despite the strong differences between these areas. This made vector control less ineffective in some areas and more ineffective in others when observing the overall progress of the past decade.

Another reason that vector control in the Gran Chaco failed is because the authorities working on vector control believed there was not a lot of genetic variety in the T. cruzi parasite and, thus, believed the parasite could be removed in a persistent, but clean sweep. This idea was debunked when strains of the Chagas-causing parasite did, in fact, become resistant to the pyrethroid insecticides, causing an increase in the fittest parasites and a decline in the weakest. With more resistant T. cruzi parasites breeding and multiplying in the Gran Chaco, vector control has become much more challenging. Adding to this challenge is that professional spray teams and householders who were involved in vector control efforts do not perform procedures accurately all the time, causing improper and inadequate efforts. These efforts either worsen the problem by creating super-adaptive bugs or reduce the problem in a cost-ineffective way by generating a situation in which spraying and re-spraying efforts are needed when they should not be.

Gürtler says that the third cause of vector control programs failing is the constant change in the world, which is hard to predict and control. Social, economic, and political change can cause some programs to gain or lose funding. Lack of cooperation between health authorities due to instability in political climates can also create inefficient and uncoordinated efforts to eradicate T. cruzi infestation near human civilization. Different administrations taking over the public health of a country causes programs to frequently alter. Additionally, changes in geography due to massive deforestation, habitat destruction and deterioration, and mismanagement of deforested regions has caused the parasite to increasingly host itself in houses rather than the wilderness, causing Chagas disease to spread faster and further. The parasite infestation in poor housing in Cochabamba is also a result of change: poor people’s migration from rural to urban areas that cause people to live in houses that have the proper environment for T. cruzi growth.

FLICKR

Vector control requires a lot of time, effort, and coordination, but it is required because without adequate vector control, there will continue to be many cases of Chagas cardiomyopathy, one of the most fatal, yet common, consequences of Chagas disease.

Barriers to Diagnosis and Treatment Across the Phases of Chagas Disease

i. Diagnosis Barriers

Though Carlos Chagas discovered the disease entity caused by the T. cruzi parasite within the first decade of the 20th century, the consensus amongst public health experts unreservedly classifies Chagas disease as an incessant global health crisis (Gürtler 52).

Caryn Bern, a former CDC scientist who has been active in Chagas disease research in Bolivia for decades, elucidates the underlying reason of the classification of the disease as an acute crisis in her recent review article. Specifically, she asserts that cardiomyopathy is the most significant consequence of the disease, for it is a nearly inevitable source of mortality in countries like Bolivia, occurring in 20 to 30% of those infected with T. cruzi (Bern 456). Consistent with Bern’s assertion, a 2013 study based on semi-structured of infected Bolivians found that the disease incites fear and anguish due to the possibility of death, profoundly transforming the emotional condition of those affected by Chagas disease (Forsyth 7). Irrespective of the fact that cardiomyopathy is what lends urgency to the control of Chagas disease, understanding the acute phase is fundamental to any feasible approach toward controlling the disease (Andrade et al. 2). Moreover, though the current literature and research thoroughly attend to chronic T. cruzi infection, they largely neglect the acute phase (Andrade et al. 1).

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This overwhelming neglect is shocking, because the existing antitrypanosomal treatment options (nifurtimox and benznidazole) are highly effective when taken during the acute phase, with an estimated cure rate of 80 to 90% (Bern 462). Chief among these ironies, however, may seem to be that which an apt comparison produces—how the existing drugs effective in curing T. cruzi infection have not mitigated the Chagas problem, which remains the most significant parasitic disease in the western hemisphere, with an estimated disease burden 7.5 times larger than that of malaria (Bern 456). ). What produces this ostensible irony, Andrade el al. explain, is the often asymptomatic nature of the acute phase that inhibits early detection and hence effective treatment of Chagas disease (4).

And even when symptoms do develop, they are nonspecific (Andrade et al. 4). Intriguingly, the main structural impediment to diagnosis is the lack of access to confirmatory testing; the enzyme-linked immunosorbent assay required to confirm a CD diagnosis is often only available in large, urban Bolivian hospitals (Forsyth 6). Confusion surrounding the rationale behind diagnostic testing might also introduce a demand-side effect that constrains the volume of diagnosis, as confirmatory testing findings often deviate from patients’ expectations of more insightful conclusions concerning the progression of their Chagas disease (Forsyth 6).

A study across numerous health centers conducted by Doctors Without Borders and the WHO beginning in 2010, however, revealed the high accuracy and dependability of 6 out of the 11 rapid diagnostic tests that are available on the market (“No excuses”). Indeed, the existence of reliable rapid diagnostic tests radically alters the fight against Chagas, since the laboratory facilities cited by Forsyth can now be circumvented. Laurence Flevaud, MSF laboratory advisor, commented on the implications of these diagnostic tools: “It is revolutionary. We can no longer say we don’t have rapid tests to diagnose Chagas, and therefore there is no longer an excuse for not treating the affected people” (“No excuses”). In light of these accurate rapid diagnostic tests, Chagas Disease Control Programs now have a means by which they can satisfy the immense need for early detection of the disease. ii. Acute Phase Treatment Barriers

The acute phase of Chagas disease occurs when a T. cruzi infected triatome bug bites an individual, discarding its feces, which contains undeveloped T. 48

cruzi triatome bugs, near an open wound (CDC).

The infection, then, enters the blood stream (CDC).

This phase is symptomless for about 95 percent of the population that gets infected. For the 5 percent of the infected population who do experience symptoms, common symptoms are swelling at the infection site, fever, fatigue, rash, headache, swollen glands, and loss of appetite among other mild symptoms (Mayo Clinic). In rare cases, swelling of the lining of the brain can occur in the acute phase. Signs of the acute phase of Chagas usually disappear on their own, but the infection persists (Mayo Clinic). About 30 percent of untreated infected individuals, develop the chronic phase of Chagas, which can be deadly (CDC).

Treatment for the acute phase of Chagas disease requires antiparasitic medications (CDC). The two drugs that are currently available for treatment are benznidazole and nifurtimox (CDC). In the United States, benznidazole was FDA approved on August 29th, 2017 (Commissioner) but nifurtimox is still not approved (CDC). Both drugs are available under CDC protocol (CDC). Though the United States has just approved of benznidazole, this drug has been in use in Latin America since the 1970s. Side effects are incredibly common in the drugs and become more severe as the age of the patient using them increases (CDC).

Both medications are almost 100 percent effective in curing the disease if taken shortly after transmission (WHO). The effectiveness of the medicines subsides the longer an infected patient waits to be treated (WHO).

The main treatment barrier has been the supply shortage of benznidazole. Roche Pharmaceutical introduced benznidazole into the market in 1971 as Rochagan or Radanil (Alpern).7 In 2003, Roche transferred the rights to the drug to a Brazilian state laboratory called Laboratoria Farmaceutico do Estado de Pernambuco (LAFEPE). LAFEPE became the only manufacturer of the drug worldwide. As awareness of Chagas disease spread in endemic countries, more people became diagnosed with Chagas which resulted in an increased demand of benznidazole (MSF). As demand increased, a shortage of benznidazole occurred in 2011. LAFEPE gave a private company called Nortec Quimica responsibility of the active pharmaceutical ingredient (API) of the drug. The shortage occurred because LAFEPE was unable to meet manufacturing and distributing deadlines and did a poor job of distributing the drug to other countries, an effort that

7 Except where specified, the following 3 paragraphs are based Alpern’s research in Access to Benznidazole for Chagas Disease in the United States—Cautious Optimism?

was not supported by the Brazilian Ministry of Health dazole, are given to individuals in this phase. It appears (MSF). LAFEPE, Nortec Quimica, and the Brazilian the biggest barrier to treatment in this phase is the Ministry of Health lacked coordination to effectively infected individual’s lack of awareness of their health distribute the drug, also contributing to the shortage problems due to the asymptotic nature of this phase. problem.

Of course, overcoming diagnostic and treatment bar In November 2011, the Brazilian Ministry of riers in the acute phase can greatly reduce the effect of Health declared it would resolve the shortage problem. the intermediate phase of Chagas which, in turn, can 1.7 million tablets were produced and an addition 1 prevent the chronic phase of Chagas from occurring. million were kept in stock by January 2012. In 2012,

Chagas cardiomyopathy is present in the sympMSF was unsure of whether this supply would cover tomatic chronic phase of Chagas, which about 20 to 30 the demand for the drug. In 2012, a generic version percent of infected people eventually develop (Ferof benznidazole called Abarax was created by a public nandez).9 Chagas cardiomyopathy and less commonly, and private Argentine partnership between the Minis- gastrointestinal and neurological diseases induced in try of Health and Mundo Sano Foundation. An Argen- chronic Chagas, can be greatly reduced by adamant tine company called Maprimed became responsible for vector control, as was discussed in a previous section the API of benznidazole and an Argentine pharmaceu- of this paper. Though gastrointestinal diseases and tical company called ELEA developed and produced neurological disorders can be present in the chronic it. ELEA has guaranteed the production distribution of phase, this paper will discuss the barriers in treating Abarax throughout Latin America, but the rising price Chagas cardiomyopathy. of it has become a treatment barrier for patients who

There is high evidence of Chagas cardiomyneed it. The rise in price occurred because there is not opathy among rural Bolivians. The Guarani people enough of the API, resulting in an increased cost of of Bolivia are Native Americans who live in the Gran manufacturing benznidazole (MSF).

Chaco. They live in mud and stick or adobe houses,

LAFEPE and ELEA are the only distributers which tend to be infested with T. cruzi. In a cardiac of benznidazole worldwide. Nifurtimox, on the other study that took place from 2011 to 2012, infected parhand, was donated in the form of tablets to the WHO ticipants from seven indigenous Guarani communities in 2004 by Bayer Pharmaceuunderwent a physical examination and ticals after stopping producan electrocardiogram, while a subset tion in 1997. Bayer stopped underwent an echocardiogram (ECG), “It is practically impossible production because it was not to determine whether Chagas-induced for poor Bolivians, who are profitable. Bayer’s donation is cardiac problems were present among mainly the ones who get Chathe only source of nifurtimox these individuals. These examinations gas cardiomyopathy, to pay worldwide. were reviewed by at least one cardiolofor these medications” gist. Of 1137 residents 10 years or older, iii. Infeasibility of Chronic 753 (66.2 percent) were infected by Phase Treatment Options Chagas disease. Fifty-five (13.8 percent)

The intermediate phase of Chagas is sometimes of the 398 infected participants ten years or older who referred to as the asymptotic chronic phase and can were evaluated for cardiac abnormalities had at least last from a couple of months to a couple of decades one ECG abnormality that was suggestive of Chagas (CDC).8 This phase occurs in individuals who did cardiomyopathy. Abnormalities increased in older not get proper treatment in the acute phase of Chapeople, which is consistent with there being a 10-to gas disease. In this phase, the infection is still in the 20-year intermediate phase in which complications of blood stream and serious cardiac, gastrointestinal, or Chagas are progressing, but not potent. neurological problems begin brewing. Since no symp- In Bolivia, Chagas is largely concentrated in toms are present in this phase, infected individuals are rural areas, but Chagas cardiomyopathy is seen in high unaware of their looming health problems. It is recom- rates in urban areas as well because in the past few mended that anti-parasitic treatments, such as benzni- decades, many rural people have migrated to urban 8 The following paragraph is based on articles published by the Centers for Disease Control (CDC).

9 The following three paragraphs are based on the findings of Fernandez in Electrocardiographic and Echocardiographic Abnormalities in Residents of Rural Bolivian Communities Hyperendemic for Chagas Disease.

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areas, carrying their infections with them (Hidron).10 A cardiac study that took place in a public hospital called Hospital Universitario Japonés in Santa Cruz, Bolivia revealed that nearly 60 percent of symptomatic congestive heart failure hospitalizations was a result of Chagas cardiomyopathy. 251 (64 percent) of the 394 participants confirmed T. cruzi infection by serology.

Serology is a laboratory technique in which blood serum is analyzed to detect antibodies present for a disease or infection. Of 342 patients, 155 (45 percent) had symptomatic congestive heart failure. 91 (58.7 percent) of these 155 patients had Chagas cardiomyopathy, while 23 (14.8 percent) of these 155 patients had T. cruzi infection but with a different cause of their cardiac problems. The study also found that mortality was higher among cardiac patients who had T. cruzi infection than those who did not. 79 percent of deaths in patients with advanced congestive heart failure occurred in people with T. cruzi infection. These results show a much higher association between Chagas and congestive heart failure in Bolivia than facility-based data found in a 2009 publication, which found that Chagas disease caused 6 to 22 percent of congestive heart failure cases and 8 percent of congestive heart failure deaths in Brazil and Argentina (Bocchi). The data in Brazil and Argentina indicate that Chagas is still relatively a major problem in Bolivia, especially because of the high fatality due to Chagas-induced cardiac disease.

medications are still recommended by physicians for treating heart failure in Chagastic patients, so a cost analysis on these medications will follow in this paper.

There are no studies on the outpatient costs of medications for patients with chronic heart failure in Bolivia, but there are studies on this topic in the United States. One study compared the outpatient costs of heart failure medications during the different phases of heart failure that are classified by the New York Heart Association (Hussey).12 The study was conducted by reviewing the charts of 138 patients with heart failure and then reviewing the outpatient costs of the medications prescribed to these patients. The authors found outpatient costs of these medications by looking through the Web sites of three commercial pharmacies and classified these medications by type according to the classification system of the American Heart Association. This study was limited in scope because the patients in this study all had the same physician, but the authors still believe this study is important because it shows what the costs of heart failure medications may be for the general population.

The results of the study indicate that the mean number of medications taken by each patient daily was 10.53. The mean number of medications by class were 8.36 for class I, 13 for class II, and 11 for both class III and class IV. Though the mean number of medications is quite high, it is important to note that many of these patients had coexisting conditions. The two most common non-cardiovascular conditions a. Chronic Heart Failure Medications that were found in the study population were diabetes Patients with Chagas disease usually mellitus and chronic obstructive puldevelop chronic heart failure, a manmonary disease (COPD). 16 percent of ifestation of Chagas cardiomyopathy, “Despite the global patients had COPD and chronic heart about twenty years after their initial progress and, in parfailure, 21 percent had diabetes mellitus ticular, Latin America’s diagnosis of Chagas (Mora).11 Treatand chronic heart failure, and 16 pernontrivial strides toward ing ventricular dysfunction and heart cent had COPD, chronic heart failure, the control of Chagas failure requires medication, specifiand diabetes mellitus. This means the disease, merely 1% of cally angiotensin-converting enzyme remaining 47 percent of patients had patients infected with inhibitors or angiotensin receptor chronic heart failure only.

T. cruzi have access to blockers and adrenergic beta-block The overall mean monthly cost treatment” ers along with diuretics/digoxin and of prescribed medications per patient other medications to decrease morwas US$438. When reviewing the cost bidity and mortality. These medicaof medication by class without accounting for coextions have proven to be effective in reducing morbidity isting conditions, the cost of medication is highest and mortality in non-Chagastic patients with heart for patients in class II at US$541. The mean monthfailure, but almost none of these studies have observed ly costs were US$314 for patients in class I, US$514 Chagastic patients. Nonetheless, it appears these

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10 Except where specified, the following paragraph is based on the findings of Hidron in Chagas Cardiomyopathy in the Context of the Chronic Disease Transition.

11 The following paragraph is based on the findings of Mora in Chagas Cardiomyopathy.

12 The following five paragraphs are based on the findings of Hussey in Outpatient Costs of Medication for Patients with Chronic Heart Failure.

for patients in class III, and US$438 for patients in rehabilitation is an effective way to prolong lives and class IV. A post hoc Scheffe test showed that the cost prevent future cardiac issues (Balady), and research differences between patients with class I and III and has suggested that cardiac rehabilitation could be helpbetween patients with class I and II were statistically ful for patients who have had cardiac problems due to significant, showing that the severity of the condition Chagas disease (Ragupathi). usually corresponds to higher costs. When accounting A study that reviewed all the electronic datafor the most common coexisting conditions, the mean bases from January 1, 1980 to May 31, 2013 on cardiac monthly costs were US$340 for patients with chronrehabilitation in low-middle income countries only ic heart failure only, found 34 articles that US$308 for patients satisfied inclusion with chronic heart and exclusion criteria “In Bolivia—a country Peter Hotez refers to as failure and diabetes (Ragupathi).13 Us“ground zero for global Chagas disease”— upwards mellitus, US$600 for ing these articles, the of 6% of the population is infected with the disease, patients with chronauthors found that amounting to the highest prevalence in the world” ic heart failure and the number of cardiac COPD, and US$730 for rehabilitation propatients with chronic grams ranged from heart failure, COPD, and diabetes mellitus. A post hoc 1 in Algeria and Paraguay to 51 in Serbia. Physician Scheffe test showed that the cost differences between referral rates for cardiac rehabilitation range from 5 patients with chronic heart failure only and patients percent in Mexico to 90.3 percent in Lithuania. Since with chronic heart failure and COPD and between Bolivia is more like Mexico in economy and location patients with chronic heart failure only and patients than Lithuania, Bolivia probably lies in the lower end with all three chronic conditions were statistically of the spectrum of the rate of physician referrals for significant, exemplifying that costs usually go up when cardiac rehabilitation.14 Primary care physicians’ lack a patient has several coexisting conditions. of cardiac referrals poses a huge barrier to cardiac

These medication costs are mostly out-ofrehabilitation participation because without a referral, pocket in the United States and so Americans deeply patients cannot get specialized cardiac treatment. The struggle to pay for them. The burden that would be study also found that attendance rates ranged from put on Bolivians if they were using these medications 31.7 percent in Bulgaria to 95.6 percent in Lithuania, is enormous. In 2016, Bolivia’s GDP per capita was with a strong correlation for higher participation rates US$3,104.96. Since the overall average monthly cost of among more educated people. Many Bolivians who medications was US$438 per patient, Bolivians would have developed the chronic phase of Chagas either live be spending over US$5000 on heart-failure medicaor used to live in rural, uneducated areas, suggesting tions, almost twice the GDP per capita. It is practically that the participation rate among Bolivians is also subimpossible for poor Bolivians, who are mainly the ones optimal.15 However, it is more important to first ensure who get Chagas cardiomyopathy, to pay for these med- that physicians refer their patients to these cardiac ications. rehabilitation programs before worrying about attendance rates. b. Cardiac Rehabilitation

Though the lack of physician referral in Bolivia

Cardiac rehabilitation is a program that aids is a major supply constraint, there is also low cost-efpatients who have had severe cardiac problems in fectiveness in implementing cardiac rehabilitation preventing future cardiac issues, prolonging their lives programs in Bolivia without affordable cardiac reha(American Heart Association), increasing their recov- bilitation models (Oldridge).15 By 2030, it is projected ery rate (Balady), and optimizing their heart function that 80 percent of all cardiovascular disease-related (Balady). Cardiac rehabilitation can involve exercise deaths and disability-adjusted life years will occur in counseling and training, education for heart-healthy the 139 low- and middle- income countries. The World living, and stress management counseling (American Health Organization has outlined three categories for Heart Association). Research has shown that cardiac 13 The following paragraph is based on the findings of Ragupathi in Availability, Use, and Barriers to Cardiac Rehabilitation in LMIC 14, 15 Please note that this sentence is an inference made based off of Ragupathi’s study.

15 The following 2 paragraphs are based on the findings of Oldridge in Cardiac Rehabilitation in Low-and Middle-Income Countries: A Review on Cost, Cost-Effectiveness.

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cost-effectiveness: ‘highly cost-effective’ occurs at less than GDP per capita, ‘cost-effective’ between one and three times the GDP per capita, and ‘not cost-effective’ at greater than three times the GDP per capita.

Cardiac rehabilitation models for patients with heart failure were found to be cost-effective in Brazil with an estimated US$18050 per life year gained (LYG) and US$22560 per quality-adjusted life year (QALY).

These models were found to be highly cost-effective in Colombia with an estimated US$3156 per LYG and US$998 per QALY. Unfortunately, Brazil and Colombia were among few of the 139 low- and middle-income countries that could have cost-effective cardiac rehabilitation programs. This is unfortunate because low- and middle-income countries need cardiac rehabilitation programs the most.

Unlike Brazil and Colombia which are both middle-income countries, Bolivia is a lower middle-income country and, thus, unfortunately, implementing cardiac rehabilitation programs is not cost-effective.

In Bolivia, public health care costs are US$6 per appointment and US$216 every three months while out-of-pocket expenses are US$7 per appointment and US$252 every three months. These expenses are astronomically high considering that Bolivia’s GDP per capita was US$3,104.96 in 2016. Bolivia’s total medical expenditure per capita in 2013 was US$149, indicating that few Bolivians were participating in cardiac rehabilitation programs, much less getting more expensive treatments such as pacemakers and organ transplants. c. Pacemakers for Arrhythmia

A person in the chronic phase of Chagas disease can develop arrhythmia (Mora), an irregular or abnormal heartbeat (Medline Plus). When arrhythmia is serious, patients usually require a pacemaker, a device implanted near the heart that uses electrical pulses to prompt the heart to beat (Medline Plus). In a Bolivian cross-sectional study of 332 patients with pacemaker implants, 17.1 percent had T. cruzi antibodies, meaning that they had Chagas disease (Mora).

In the Hospital San Juan de Dios, the largest public hospital in Santa Cruz, Bolivia, about 40 pacemaker implantations and battery replacements are performed annually (Clark).16 A separate study reported that 72 percent of all pacemaker recipients in a Brazilian cohort were seropositive for T. cruzi infection, underscoring the large role that Chagas disease plays in the number of cardiac patients and deaths in 52

Latin America. Since the Santa Cruz hospital serves as the referral hospital for all southern Bolivia, including the Gran Chaco, data from this hospital is indicative of the needs of cardiac patients who seek care. However, since physician referral rates are quite low in Bolivia, probably ranging between 31 to 80 percent, data from this hospital is not indicative of the needs of all potential cardiac patients. Since the Gran Chaco is highly populated with people infected with Chagas, it is likely that many patients in need of pacemakers are seropositive for T. cruzi in this Santa Cruz hospital. The cost of the surgery and device is approximately US$5000, which is about 1.5 times Bolivia’s GDP per capita, meaning that only the most affluent patients or the rare patients who have private healthcare coverage can afford pacemaker services.

Three cost-reduced pacemaker programs have been implemented in the past decade or so but supply constraints including broken surgical equipment and import barriers have resulted in only 170 to 200 pacemaker implantations even though there was a need for about 1800. One of the programs is estimated to have implemented 100 pacemakers every year from 2005 to 2010 but a crucial piece of surgical equipment stopped functioning and the hospital, nor the organization could afford to provide a replacement. This program charged patients on a sliding scale and was quite effective until capital was lost. Another program that implanted 30 to 40 pacemakers annually was shut down in 2012 because of import barriers that prevented donated pacemakers to be distributed overseas.

This program was also effective and charged patients US$800 for the surgical procedure but gave them free pacemakers. The third program was halted due to unspecified reasons. It is clear that there is a lack of money and a cooperation framework in supplying pacemakers even though there is a pertinent, massive, and urgent demand for it.

CONCLUSION

Comparing 1991 and 2010 estimates of the global magnitude of Chagas disease could be misleading, because prevalence figures have fallen some 60% during this time (Bern 1). Despite the global progress and, in particular, Latin America’s nontrivial strides toward the control of Chagas disease, merely 1% of patients infected with T. cruzi have access to treatment.

Chagas disease is, indeed, the most significant parasitic disease in the Western Hemisphere, evidenced by its estimated disease burden, which is roughly eight

16 The following two paragraphs are based on the findings of Clark in Hyperendemic Chagas Disease and the Unmet Need for Pacemakers in the Bolivian Chaco.

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times greater than that of malaria (Bern 1). And in Bolivia—a country Peter Hotez refers to as “ground zero for global Chagas disease”— upwards of 6% of the population is infected with the disease, amounting to the highest prevalence in the world (“The New Numbers”). In seeking to offer an analysis to understanding why Bolivia is the most highly afflicted country, not only on the regional level but also globally, this paper attempted a disentanglement of the problem, exploring the following research questions: What are the current problems and challenges associated with Bolivia’s Chagas disease control programs, that is, in terms of epidemiology, vector control, clinical management, diagnosis, and treatment? And why has the 2006 declaration of Chagas disease as a national priority via Law 3374 not effected meaningful progress in terms of disease control? This paper undertook a historical review of the sociopolitical and economic variables that influence the health of the population, a comprehensive review of the literature delineating the obstacles to diagnosis, treatment and disease control, and an

in-depth investigation of the country’s health system.

Through this tripartite analysis, this paper reached a few conclusions that synthesize the existing research concerning Bolivia’s Chagas problem, the implications of a problematic health system, and the fundamental constraints on clinical management in addition to vector control. The literature that comprises the current body of research is generally segmented, with much of it attempting to precisely understand and conjecture an optimal solution to some individual element of the issue, whereas this paper provides a multidimensional analysis from which only a general prescription, for an unthinkably nuanced and dreadfully neglected disease, might be deduced.

This paper demonstrated how recurring interaction between Bolivia’s remarkably diverse majority and the historical domination of the controlling minority, composed of mestizos and people of European descent, reproduces a culture of discord, its manifestation being chronic political instability. In this way, the past century of Bolivian politics and government has 53

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been characterized by an oscillation between populist and anti-populist poles. It is unclear, however, whether this oscillation will persist in light of the massive shift toward socialism, which was effectuated by Evo Morales and the MAS in 2006. It seems as though the indigenous political movement, galvanized by and tired of the assault on the mores of the diverse majority, which began to gain traction in the 1980s and 1990s, has obtained a significant position in Bolivian society, one that makes plausible the vision of a “multi-ethnic Bolivia.” Toward that end, the Morales administration re-wrote the Bolivian constitution, advancing the indigenous rights agenda, among others. It, too, managed to facilitate a break from the country’s record of poor economic performance, in terms of stability and long-run dynamism, owing to the issue of income distribution, the largely embraced notion of state-run capitalism, and geographical dispersion. In fact, the country has seen its best and most stable GDP growth under Morales, as the government has been consistent with combatting a series of shocks with expansionary fiscal policy and conducting reasonable monetary policy—a noteworthy departure from the historical corruption and ill-conceived policy which, for instance, led to the hyperinflation seen in the 1980s. The very fact that the Bolivian economy has entered an era of relative economic growth and stability, however, does not wholly illustrate the country’s position. Bolivia is still plagued with extreme levels of poverty, among the worst in Latin America, and this reality has dire implications for health; the country ranks below Algeria and Botswana with respect to equality. It is rather confounding that the Morales government, one which has professed its commitment to an eventual universal health system, has continued prior administrations’ policy of inadequate budgetary allocation to the health sector. Bolivia has, and continues to, spend significantly less on healthcare than the two countries with the most similar GDP’s, having a health budget that is roughly half of that of Costa Rica. The aforementioned progress that the Morales administration has made is overshadowed by the persistence of rampant socioeconomic inequality and comparatively minimal budgetary allocation to health, a reality echoed by the MSF Program Manager for Bolivia. As a result, the country’s decentralized health system still struggles with distressing levels of segmentation, fragmentation, and inefficiency, leading to limited and, at times, nonexistent resources for the clinical management of Chagas disease.

This paper also demonstrated how the fundamental challenges of Chagas disease control programs are particularly inhibitive in Bolivia. Though an integral and indispensable element of disease management, vector control efforts have been far from effective due to the inefficient and uncoordinated implementation of initiatives that embodies the Bolivian health system. Comprised by the MoH in addition to Social Security at the administrative level, SEDES at the departmental level, and the local or municipal systems at the operational level (DILOS), the convoluted and weak Bolivian public health system, on which the vast majority of the population relies, could modestly be described as inadequate. The public sector’s vector control efforts, for instance, have failed the hyper-endemic Gran Chaco region. Furthermore, the poor provision and delivery of the drugs manufactured to treat T. cruzi infection during the acute phase have resulted in supply shortages and differential supplies.

It, too, must be observed that clinical management of Chagas disease during the chronic phase leads to astronomical out-of-pocket costs, which most simply cannot afford, and health centers regularly lack the well-functioning equipment and medical training that chronic phase treatment demands. The fact that there are two drugs, which if taken as prescribed during the acute phase, are highly effective in treating T. cruzi infection, should offer a solution to those afflicted by Chagas disease. However, the reality is that diagnostic tests, until recently, were often only available in large, urban hospitals by virtue of the complex testing process, and the public health system has yet to integrate the revolutionary rapid diagnostic technologies into primary healthcare centers in endemic regions. Even if treatment is guaranteed at a feasible cost, an additional problem is that, akin to the primary constraint on chronic phase treatment, treatment implies follow up appointments, which generate further out-of-pocket expenses. Largely poor, marginalized, and neglected, most Bolivians are not provided with access to diagnostic testing and affordable treatment options, a failure for which we must hold the health system and, as such, the central government accountable.

The pressing question, then, must be: what can we done? Given this paper’s conclusions, what might we hope for or, in other words, look to as a model for mitigating the impact and magnitude of Chagas disease in Bolivia? An interpretation of our findings that accounts for recent economic and social progress, the fundamental obstacles to Chagas disease control, but

also a persistent institutional deficiency, particularly with regard to healthcare could consider a recent success story as a hypothetical model for Bolivia. ISGlobal and the CEADES Foundation created the Platform for the Integral Care of Patients with Chagas Disease in 2009, a collaborative initiative with the MoH. The Bolivian Platform sought to train medical staff, ensure the provision and delivery of diagnostic tests and treatment, and facilitate research. From its inception until 2015, the platform the platform saw roughly 25,000 people, of which some 21,000 tested positive for T. cruzi infection. And of those patients who pursued care, upwards of 80% completed treatment. Despite the success of the Bolivian Chagas Platform and the fact that the MoH has utilized it ass the basis for a new model being implemented to health centers across the country, interpretations rooted in this reality together with this paper’s findings may be quite divergent.

Chagas disease remains a seemingly intractable problem due to international neglect and an insufficient Bolivian public health system, but a few recent developments in the spheres of governance and international collaboration telegraph some degree of hope for those impacted by this disease. Recent technological developments, social and economic growth, and a successful model might begin to effectuate belief in and progress toward the possibility of universal access to Chagas treatment.

APPENDIX

Bolivia is a nation whose postcolonial history has an identifiable beginning with many understood elements, which is revolutionarily and otherwise consistent with the narrative of Latin American independence. Though insofar as demographics are concerned, Bolivia is distinct from the rest of South America, with its ethnic majority comprising the largest proportion of indigenous peoples in the region; between 44 and 62 percent of its people either speak a language of or identify with an indigenous group (Watson; “South America”). The country also has an ethnically-distinct, elite minority constituted by mestizos and people of European descent, which was politically and culturally dominant from the colonial era through the onset of the 21st century—this power asymmetry, Quijano reasons, is a derivative of the “coloniality of power” (567).

A description of Bolivia’s sociopolitical environment formed exclusively on the modicum of information provided above would delineate somewhat of a typical case of the product of European imperialism: the

unilinear path of long-run domination sustained by a power structure attributable to colonial-era relations.

This model of sociopolitical development, however, is necessary but insufficient in understanding modern-day Bolivia. Reason being, one of only two democratic revolutions that have happened in the Americas, excluding the U.S. War of Independence, occurred in Bolivia (Quijano 572). An accurate depiction of Bolivia, then, ought to emphasize the sui generis nature of the interactions between its strata. Within this ethnically divided society, the elite minority reproduces its historical domination through the logic of and power structure entrenched in colonialism, creating a culture of enmity—precisely what led to impactful indigenous resistance in the 1952 Revolution (Healey 89). The country’s acute political instability, and more specifically the oscillation between populist and anti-populist politics, reflects its deep, ineradicable ethnic division (Sachs and Morales 3).

Bolivia is known for having protests that cause bloodshed, a proclivity for coups, and economic turbulence, such as the hyperinflation of the 1980’s (Painter; Sachs and Morales 1). Despite its history of political instability and international reputation, Bolivia has experienced relative stability following the profound economic and political crisis of the 1980’s (Painter 2005). In an attempt to secure free markets in the region, the International Monetary Fund and the World Bank gave conditional loans to Bolivia, obliging the neoclassical economic reforms implemented in 1985 (Postero 21). ). Meanwhile, the quickly expanding national indigenous movement, galvanized by NGOs and progressive religious groups, began issuing new demands of increased recognition and collective land rights; cultural and ethnic concerns being most central to these demands, and not issues of class, the Sánchez de Lozada administration reasoned to integrate them into a series of neoliberal reforms (Postero 22). Following the economic crisis of the preceding decade, the 1990’s in Bolivia saw consistent GDP growth, picking up to about 4% annually with the exception of 1999 (“Bolivia GDP”). The eventual failure of Bolivia’s neoliberal multiculturalism to curb endemic racism and to effect tangible political change, despite increased national stability owing to improved macroeconomic conditions, heightened indigenous frustration (Postero 23).

Healey cites decentralization reforms as significant sources of symbolic traction for indigenous political leaders who were no longer willing to see their

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people endure the indignities imposed by the elite, and so they advanced the Movement for Socialism (84).

More specifically, the multicultural neoliberal reforms of the 1990’s, such as Ley de Participatión Popular of 1994, even without an immediately measurable effect on inequality, did engender a new era of Bolivian policy and discourse that attended to issues of indigenous citizenship (Postero 22). The aforementioned legislation, for instance, recognized the role of largely indigenous local governments in municipal development, giving way to a new era of governance centered on decentralization (Prud’ homme et al. 4-5). And as the Movement for Socialism (MAS) began to produce increasingly viable political candidates, one stood out by virtue of rhetoric: Evo Morales. In particular, his populist rhetoric telegraphed hope for those who had long been neglected, envisaging a “cultural democratic revolution” grounded in indigenous autonomy, socialism, and Bolivian nationalism (Postero 18). Today, the MAS is represented at the highest level of government

by President Evo Morales who assumed office in January 2006.

Bolivia’s sociopolitical history, then, is ultimately a story in which domination by the elite was transmogrified into the democratic reacquisition of power by the country’s indigenous majority. What proves most revealing about an examination of modern Bolivian history, though, is the mental dynamism of the marginalized, the “new indigenous consciousness,” displayed at the end of the 20th century—how the ways in which the Bolivian elite had retained power for centuries would serve to undermine their historical dominance (Healey 85). That is, the Bolivian elite unwittingly ushered in a new sociopolitical era, one that challenges the traditional power structure, in precisely the same ways by which they had maintained that hegemony, as their domination ultimately mobilized the majority’s frustrations.

We can extract two facts from understanding the determinants of sociopolitical instability in Bolivia.

First, much of the underlying ethnically-rooted tension between Bolivia’s historically dominant, elite minority and its indigenous majority remains unresolved. Second, this ubiquitous tension renders Bolivia vulnerable to both brutal political hegemony and massive swings in the governing political ideology.

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Rusha Majumder is an undergraduate sophomore at Emory. She is majoring in Economics and Mathematics/ Computer Science while completing the pre-medical requirements. She is currently an intern at an investment bank called Leonis Partners and a research assistant at a biomedical informatics lab at Emory. She is also the founder of Emoryâ&#x20AC;&#x2122;s Business of Healthcare club and is on the executive board of the Emory Economic Student Society and the Emory Pre-medical Association. She would eventually like to end up working in healthcare finance.

Joseph Medeiros is a sophomore at Emory, majoring in Mathematics/Economics and Latin American/Caribbean Studies. He recently served as an Intermediate Microeconomics TA, aiding in instruction, hosting problem-solving sessions, and giving supplemental lectures that covered the foundational mathematical concepts germane to the course. Previously, he was an editorial assistant at The National Interest, a foreign policy magazine published by a Washington-based think tank, where he regularly engaged with expert panels. He is currently interested in the ways in which cultural differences and historical factors shape the behavior of states and also how this interaction can be integrated into mathematical economic modeling.

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