Only in Bolivia…

The end of my practicum experience felt like it appeared out of nowhere. Friday, March 30 was my last full day and I couldn’t shake the feeling that I had just arrived only a few days before. Four weeks absolutely flew by and it was bittersweet when my flight left La Paz on 3/31.

I expected some sort of adjustment period or reverse culture shock, but aside from the spring-disguised-as-winter weather, I’ve had no issues adjusting to being back home. I was fortunate to stay in a very nice apartment with excellent water pressure, so I didn’t have issues adjusting to rustic-then-luxury accommodations. And we’ve got bad drivers, sudden weather changes, and a lack of respect for personal space in Chicago, too.

I do, however, miss La Paz’s personality and quirks. Where else can I find things like:

The weirdly aggressive (and judgmental?) store mannequins. US mannequin dressers are lacking some serious imagination. I’d be willing to buy something just to make these mannequins stop staring at me.

 

The llama-fication of everything! I don’t have a special affinity for the actual animal, but everything is a little more fun when it’s dressed like a llama.

 

Mixed public health messages. The sign on the left very bluntly states “Trash Kills” and announces fines for littering. The picture on the right was taken one block from this sign. This cluster of power lines remained low like this for an entire week before it was finally repaired. This is what it looks like to live and work in a resource-limited setting: public health gains and losses exist side by side, without complaint, because everyone knows the city will fix it when they can fix it.

 

The traffic zebras and donkeys! Thanks to John Oliver, I was aware of the traffic zebras – they encourage safe driving and pedestrian behaviors – and they were really fun to see in person. But I didn’t know that there are also traffic donkeys! They aren’t out as often as the zebras and they aren’t playful. They tend to scold people for unsafe driving and pedestrian behaviors. It’s surprisingly effective – it does feel a little shameful to be teased by a walking plush animal.

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Syncretism (sincretismo): the fusion or mixture of Catholicism or Christianity and indigenous religious beliefs. Bolivia is a predominantly Catholic country, but many people also observe indigenous religious traditions.

In the Mercado de la Brujas (witches’ market), you can find all the supplies you’d need to make an offering to Pachamama, the Mother Earth goddess. Offerings include sugar candy (because Pachamama loves sweets), small candy plaques decorated to represent a special hope or wish (better job, a new child, etc), and dried llama fetuses, which represent a meaningful financial sacrifice. At night, the offerings are placed in a fire and left to burn overnight. If there is nothing but ashes left in the morning, then Pachamama has accepted your offering and will grant your wish. If the offering didn’t fully burn, Pachamama did not like your offering, and you have to make another, bigger offering. It is not unusual for people to attend mass and then burn an offering to Pachamama later that same week.

In the picture below, the statue on the left is Ekeko, the god of abundance. The statue is decorated with items that represent cultural, financial, and person abundance, such as a pan flute, money, flowers, foods, and various farming implements. Every day, the store owner puts a fresh cigar in his mouth – if it burns all the way down, Ekeko will grant your wish. If it doesn’t, you just have to hope that Ekeko will be in a better mood tomorrow. (Side note for the single ladies – Ekeko is needy and demanding of attention. Single women are “prohibited” from buying Ekeko icons because it is believe that Ekeko, out of jealousy, won’t bring them a husband.)

The market also sells spell potions and soaps – in the picture below, the Sabonete is meant to ward off domestic violence. There other potions and powders can help you find love, find a job, treat minor ailments, etc.

 

Vibrant street art, including sculpture, murals and graffiti. I didn’t get an opportunity to take a lot of pictures of the graffiti, but in general, it is very political in nature, and the messages change across city neighborhoods. Where I lived, most of the graffiti was very anti-Evo Morales – a lot of “Evo es dictador” (Evo is a dictator). In the older parts of the city, and in areas predominantly populated by indigenous persons, the graffiti was very pro-Evo – a lot of “Evo sí” (yes to Evo) and “Si no es Evo, quien?” (if it’s not Evo, then who?).

The most common message in all parts of the city was “Mi voto vale”, meaning my vote matters. The US has struggled with electoral apathy for a very long time. It was refreshing to be in a country where people are very engaged in politics and believe in voting.

(Some background info – Evo Morales cannot run again because of term limits. He held a referendum to change the constitution to allow him to run an unlimited number of times, and the Bolivians strongly voted No. However, Evo does not want to leave office, and while Bolivians like and appreciate his reforms, they believe he needs to honor their constitution and their vote.)

 

The traffic light countdowns! We really, really need these in the US. When the light is red, the clock that will count down the seconds until the light changes. Once the red countdown is finished, the yellow light will come on and a green clock will count the seconds until the light turns green. This builds in a few seconds between light changes to allow the intersections to completely clear. When the light turns green, a green clock will count down the seconds until the light turns red. Did i mention that we really could benefit from these in the US?

 

The very entertaining television shows that seem to be a mix of talent show and telenovela. They go all in on the costumes.

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Mostly, though, I will miss my co-workers and friends, who showed me an enormous amount of generosity, courtesy, and affection during my time in La Paz.

Get in my belly!

Half of the fun of traveling to new places is trying new or unfamiliar foods. As a vegetarian, I haven’t been able to try too many typical Bolivian dishes, but here’s a list of what I have tried:

Cuñape – a type of bread made from yuca (cassava) flour and cheese. For such a simple food, it is ridiculously yummy and makes for the perfect snack. Or meal, because it’s hard to limit yourself to just one.

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Empanadas – most people are familiar with empanadas, but there are so many filling options that we don’t typically see in the US. These empanadas are pretty simple – one is filled with cheese, the other is filled with cheese, tomato, and basil.

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Salteña – a salteña is like an empanada, but the filling is like a stew. You definitely need a spoon and a lot of napkins to eat one of these! Typical fillings are beef, chicken, or ham and cheese. The vegetarian one (pictured below) is filled with a sort of veggie stew containing broccoli, onions, and carrots. Some places also offer a mushroom version, but I haven’t had a chance to try it.

Chuño – a chuño is a freeze dried potato. There are two types – black potatoes and white potatoes. These potatoes are typically made by the Quechua and Aymara, but they pre-date the Inca civilization. The potatoes are freeze dried through a natural process. In June and July, the potatoes are laid out in a single layer and left to dehydrate in the sun and then freeze overnight. The process typically takes 5 days, but these potatoes can last up to 10 years with proper storage. They’re a critical staple for farmers, as they provide a reliable food source during unfavorable farming seasons.

These potatoes are usually steamed or boiled to rehydrate them. I’ve tried the black potatoes and didn’t much care for them. They weren’t bad per se, but they have a very earthy taste that I didn’t quite like. I think these are probably an acquired taste.

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Torta de Choclo – this is a cake made with corn, but it’s nothing like cornbread. It’s quite creamy, has a somewhat buttery flavor, and has just the right amount of sweetness. It’s almost like a cake made out of creamed corn, minus the corn kernels. One thing I really like about Bolivian pastries is that they are not overly sweet!

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Queso Humacha – humacha cheese is a traditional dish of La Paz, and is typically eaten during Semana Santa (the week leading up to Easter). It’s normally prepared as a stew, but I had a sandwich version that was really good. It contains corn, cheese, and beans (don’t know what they’re called, but they looked like larger, flatter lima beans) mixed in a spicy yellow sauce. Definitely recommend trying this if you have the chance.

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Torta de Cinco Leches – this cake is very similar to Tres Leches cake, except it is made with 5 different types of milk instead of 3. Very very very good cake. Sometimes tres leches cake takes on a soggy or oversaturated texture. I was a bit hesitant to try this cake, thinking it would suffer a similar fate, but I needn’t have worried. It was moist, light, and had a subtle, milky flavor. The multiple types of milk were not overpowering or too sweet.

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Coca Candy – Last, but not least, is candy made from coca leaves. Considering how much coca leaves are used medicinally in Bolivia, I was not surprised to learn that it comes in a candy form. It tastes a bit like a mild, slightly sweet licorice and is supposed to be good for headaches and stomach ailments. (The flavor is good, but hard to describe, because it doesn’t taste quite like anything else I’ve had.) It also makes your tongue and mouth a little bit numb.  Be warned – you cannot bring this candy back to the US. While there are no illegal substances in the candy, drug sniffing dogs have been trained to find it so that customs can confiscate it. Bottom line: this is a food that can only be enjoyed in Bolivia.

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Pass the salt, please

Even though I am here for school purposes, my practicum program gives us time to explore La Paz and Bolivia. I spent this past weekend in Uyuni, Bolovia, home to the world’s largest (and highest) salt flat!

I know, I know…visiting a salt flat sounds boring and/or lame, but it was actually quite beautiful. My tour started with a drive past fields of red quinoa plants. According to Bolivians, the best quinoa in the world comes from these fields, as the minerals in the soil create a very nutritious and uniquely tasty grain.

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Next stop was the train cemetery in Colchani. The train tracks that run through here are the original tracks that carried silver and other minerals from Potosí to the coast for sale and distribution. Since Bolivia no longer has a sea port, these tracks now lead to Chile.

 

I have no idea why a place where trains go to die is a tourist attraction, but it was kind of cool to explore train cars up close. Lots of tourists climb the cars. I might be current on my tetanus shot, but I wasn’t willing to push my luck.

After visiting the train cemetery, we visited the small town of Colchani. There is a small museum here that is supposed to be about the salt mining and manufacturing process, but it mainly focused on llamas. I can’t say I learned anything at this museum, but it did have some very entertaining miniatures.

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Colchani also has a row of stalls selling various handicrafts and items made from salt. It took every single bit of self control I had not to buy one of these stuffed llamas/alpacas. IT’S SO FLUFFY I COULD DIE!

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After leaving Colchani, we headed straight for the salt flats. I’ll let Wikipedia provide us all with some basic info: “the Salar de Uyuni is the world’s largest salt flat at 10,582 square kilometers (4,086 sq mi). It is at an elevation of 3,656 meters (11,995 ft) above sea level. The Salar was formed as a result of transformations between several prehistoric lakes. It is covered by a few meters of salt crust, which has an extraordinary flatness with the average elevation variations within one meter over the entire area of the Salar. The crust serves as a source of salt and covers a pool of brine, which is exceptionally rich in lithium. It contains 50% to 70% of the world’s known lithium reserves, which is in the process of being extracted. The large area, clear skies, and exceptional flatness of the surface make the Salar an ideal object for calibrating the altimeters of Earth observation satellites.”

It is currently the rainy season in Bolivia, so the Salar is covered in rainwater. When I visited, the water was 4-6 inches high in some places.

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In other places, the salt is wet, but not saturated. In these areas, you can see the many colors that lie under the salt crust.

And because science is cool, here are photos demonstrating how the water effects the shape of the salt crystals. The photo on the left shows the salt crystals from the drier parts of the Salar. The photo on the right shows the salt crystals from the parts of the Salar that are underwater. Travel tip – if you visit the Salar, I would not recommend walking across it without shoes. These crystals (particularly those that are underwater) are quite sharp.

The Tunupa volcano provides enough heat to create bubbling pools throughout the Salar. These pools are similar to the geothermal pools you’d see at Yellowstone or in Iceland, except the bubbling water is very cold!

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The combination of water and calm winds creates a mirror effect. Unfortunately, the winds were pretty strong the day I visited, so I couldn’t get good pictures of the reflection of the sky upon the water. But that didn’t stop my tour group from taking all sorts of silly pictures to capture what we could of this mirror effect.

The vastness and flatness of the Salar allow you play around with proportions:

And for the tour’s final act, I got eaten by a TRex:

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The public health scourge that is Machismo

Merriam-Webster defines machismo as:

  • a strong sense of masculine pride an exaggerated masculinity 
  • an exaggerated or exhilarating sense of power or strength

Last weekend, the other practicum students traveled to Copacabana and La Isla del Sol for a little getaway. While there, they did a lot of hiking through Incan ruins. During one such hike, they saw a family with two children – one boy and one girl. Both children were crying because they were tired and struggling on this hike. The parents told the boy to “man up” and “don’t cry, men don’t cry”. Their reaction to their daughter was quite different. Simply put, they ignored her.

This is machismo (or toxic masculinity) in action: teaching boys that expressions of emotion are a weakness and emasculating; teaching girls that their voices don’t matter, that they are incapable of exercising control over themselves, that they are invisible.

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Machismo has all sorts of negative societal implications, primarily concerning domestic violence and women’s rights. However, machismo also exerts enormous influence upon women’s health.

The clinics and hospitals in El Alto, a city that is predominantly indigenous, are full of teenage girls who are pregnant, have contracted various STIs, or have developed uterine cancer as a result of HPV. And when I say teenage, I mean young women that are 13-19 years old. (I try not to judge, but I still thought boys were icky when I was 13!)

Many of these women are unaware of the basics of sexual health and their reproductive rights. Because it is so culturally ingrained that a man knows best, they don’t know how to have a conversation about contraception with their partners, and go along with whatever their partner wants. Even worse, it is acceptable for the men to walk away from their responsibilities, because raising children is “women’s work”.

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The burden of childcare and/or disease management falls entirely upon the shoulders of these women, and this is where we see how machismo also infects relationships between women.

  • Many of the pregnant teens will tell their doctors that they cannot go back to school after their baby is born, because their mothers won’t let them. This perpetuates a cycle of poverty and misinformation.
  • Many will say their mothers-in-law won’t let them work outside of the home, because their only job is to be a wife and mother. This perpetuates a cycle of financial and emotional dependence.
  • Many husbands and families will deny a pregnant woman permission to obtain a C-section, even when the life of the mother and baby are at risk, because a “real woman” delivers babies vaginally/naturally. This perpetuates a cycle of avoidable maternal and child mortality.

Each case serves as an example of how little little autonomy women have over their own bodies and health choices. Imagine having to get permission from your husband to see the doctor. Imagine having to get permission from your husband to obtain necessary medical tests and life-saving procedures. Imagine having to get permission from your husband and mother-in-law to work, because you’ve been taught that you’re only “real” job is to take care of your husband, children, and household.

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Critical public health indicators such as maternal and child mortality and rates of infectious disease will remain high until women are empowered to make their own health decisions. It is not just men that must be educated in gender equality, but women’s attitudes about their roles in society must also change.

When cultural norms conflict with public health

In 2009, Bolivia approved a new Constitution that renamed the country to the Plurinational State of Bolivia. This name was chosen to reflect the country’s diverse population – approximately 60% of all Bolivians identify as indigenous. The Aymara and Quechua are the largest of the 36 indigenous groups found in Bolivia. In La Paz, the primary indigenous group is the Aymara.

Aymara women who wear traditional dress are often referred to as Cholita women. The word Cholita has a long and ugly history, but in recent years, Aymara women have reclaimed the word and wear their traditional dress with pride.

The typical Cholita outfit consists of a tiered skirt worn over multiple petticoats, a blouse, a thick shawl, and a bowler hat. Many women accessorize with earrings and jeweled pins to hold their shawls closed. Outfits can be quite fancy or plainer, for everyday use.

Women usually wear their hair in two braids, which they embellish with plain or decorative yarn. This is really neat for me because Indian women do this as well. Even with simple yarns, it’s very pretty!

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The outfit has much significance. First, women wear many petticoats because they want to puff up their skirts as much as possible and look physically bigger. To the Aymara, looking heavy signifies wealth – it means you don’t have to do physical/farm work and/or you have an abundance of food. Having wide hips signifies fertility and having a big butt is considered attractive. We place so much value on being skinny in the US, but it’s the opposite for the Aymara. And on a personal note, it’s really nice to be in a place where you don’t feel negatively judged by your physical appearance.

The bowler hat describes the woman’s marital status. Married women wear their hat in the middle, on top of the head. Single or widowed women wear their hat tilted to the side. And, as the Aymara joke, wearing your hat tilted to the back means your relationship is “complicated”.

Make no mistake, no matter how pretty or plain the outfit, these women work hard. They often carry babies and/or various goods in a cloth sling tied around their necks.

I see them all over the city selling fruits and veggies on the street corner, managing small shops and market stalls, or collecting fares for mini-buses. They’re often carrying an incredible amount of stuff – both on their backs and in their hands. (Side note – they have incredible posture!) They are responsible for the majority of the work in their households: taking care of their husbands and children, cooking, cleaning, outside jobs/work, etc. So it’s no real surprise that they have little time available to bathe or launder their clothes regularly. It is simply not a priority.

And this is where their cultural norms conflict with public health programs. The most basic of public health programs address hygiene – major reductions in rates of infectious disease can be achieved simply by teaching people to regularly wash their hands with soap and warm/hot water. But how do you convince people who have limited access to proper housing, clean water, sewage, and sanitation systems to improve their hygiene? It’s never been a priority before, so why should it be a priority now? Where is all this soap and water going to come from? Can they afford to give up 2-3 hours per week of money-earning work to wash all of the household’s clothes and buy toilet paper?

This is the real challenge of implementing public health programs. How do you change personal behaviors, without offending the culture and its people? (The white savior complex doesn’t just apply to movies.) How do you change behaviors amongst people with very limited resources? How do you effectively educate people that may not speak the predominant language or are illiterate? It’s not enough to just tell people to improve their hygiene. There are so many factors to consider even if you’re just raising awareness. Delivering comprehensive education that is retained over the long-term requires the consideration of even more factors.

I hope to learn more about the answers to these questions during my stay in La Paz, as the majority of my research is focused on consumer education. From where I stand now, though, I will say that open-mindedness and empathy are critical to the success of any sort of educational effort.

All work and no play

Developing sustainable health policy and programs isn’t nearly as exciting as delivering vaccines to children in the hopes of eradicating deadly diseases. It’s not as interesting as developing new, life-changing medicines for new, existing, and neglected diseases. And it certainly isn’t as news-worthy as delivering emergency medical aid to those fleeing conflict. However, these programs cannot succeed in the long-term without sound, evidence-based health policies to support them.

I came to La Paz to work with a Bolivian NGO called PROCOSI. They work with other NGOs and various Bolivian government ministries to develop public health policy and promote the concept of integral health. As such, PROCOSI addresses issues of maternal mortality, low birth rate, perinatal mortality, and infectious disease via improvements in health services, access to health services, nutrition, sanitation, housing, and gender equality.

I’m working on a project designed to improve access to health services. While Bolivia does have a national health system, a large segment of the population remains uninsured and/or financially unable to obtain health services. PROCOSI has developed a micro health insurance product that offers coverage for a standard set of health services at a low-price, for qualifying individuals and their families. Developing this type of program requires a lot of research and number-crunching to determine the optimal number of health services offered, price points, and policies sold to ensure financial viability. (I told you this wasn’t exciting.)

I’ve been tasked with identifying barriers that prevent persons from purchasing or using this insurance, and researching strategies to overcome these barriers. At the moment, I’m focused on patient education programs. Bolivia doesn’t have a culture of insurance like we do in the US. This makes it much harder to sell these policies because they’re seen as an unnecessary expense.

My work is an interesting combination of research, problem-solving, and creativity. It requires thinking outside of the box to identify strategies that are both feasible and culturally-appropriate. And it’s an incredible opportunity for me to be able to work on a project that will have a lasting, long-term impact on the lives of both the people and the government of Bolivia. And that is what makes policy development exciting.

There’s no place like home

Traveling abroad requires patience and understanding. Living and working abroad requires what feels like an infinite amount of patience and mental fortitude.

Shortly after graduating from the University of Kansas, I lived and worked in Mexico for six months, so this wasn’t my first time at the rodeo. But even with that experience, I still expected that it would take some time to adjust to life in La Paz.

La Paz is a modern city that is similar to Chicago, but just different enough to make me feel off-kilter. There are so many unexpected things that prove challenging, such as:

Technology differences:

This is the Bolivian mobile phone provided by my practicum organization. Do you know how hard it is to use one of these phones when you’re used to using to an iPhone? I swear it took me 5 minutes to send a simple text message and at least 3 attempts to add a new contact. (Disclaimer – plenty of people in La Paz use smartphones, we were given these simple phones because they are inexpensive and practical.)

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My homestay has a washer and a dryer…except, the dryer doesn’t work as well as our dryers. It’s normal and preferable to line dry your clothes, which means you have to get used to displaying your drawers in public for days at a time.

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Sometimes you encounter really simple solutions to problems like keeping your windows open. In the US, “fixing” this would probably require multiple trips to Home Depot and a lot of cursing. This is a good reminder that differences can be positive, rather than negative experiences.

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Transportation differences:

In Chicago, we have a pretty good system of public transit involving trains, the el, buses, and cabs. I know how to get from point A to point B, and I know which modes of transportation are safe. La Paz has a good public transit system as well – buses, mini-buses, cabs, and a cable car system, but it is frustrating those first few days when you have no clue where you’re going or how to get there.

Last week, at the end of a very long day, I had to wait 40 minutes to catch a bus and then another 30 minutes of travel time to get back home. My RBF was beyond extreme by the time I got on the bus. In Chicago, I would have hailed a cab after the 5th full bus passed me by, but I can’t do that here in La Paz. It’s simply not safe to hail a cab off the street when you’re female and traveling alone. To add an additional layer of complexity, you can call a taxi company, but there is one number for the south side of the city and another for downtown. I was in the south side and only had the number for the downtown cab company. Remember that bit about patience and mental fortitude?

Workplace differences:

Like most non-Western cultures, time is fluid here in La Paz. It’s normal and acceptable to be late, even extremely late. This can be very frustrating, as we practicum students are expected to be on time, always. Last week, a colleague scheduled a meeting for 9am, but didn’t show up til 9:45am. And when he did arrive, he spent the next 10-15 minutes greeting others in the office and making small talk.

There are other differences in workplace behaviors – it’s considered rude to not greet your co-workers with a kiss, a good morning/afternoon, and some small talk. The office closes for lunch from 12:30-2:30 – this is one difference I can totally get on board with, as it gives you time to eat a nice meal (at home or in the office) and socialize with your colleagues. Deadlines don’t always carry the same pressure – you may send an email to someone and get a response 2 weeks later. Being aggressive and/or pushy about follow-ups and deadlines is frowned upon.

The general pace of work is slower and less frenetic. I can’t say this is a bad thing, because it gives you a nice work-life balance (something that might as well be a four letter word in the US).

As Axl Rose once said: All we need is just a little patience.

Food/culture differences:

I love exploring local markets – they’re always so colorful and carry so many foods that we don’t get in the US. This weekend, I went to two different markets:

That first picture is a papaya. I have never seen a papaya that ginormous, hence the reason I took a photo of it. 🙂 These markets carry so many root vegetables and giant squashes that are unfamiliar (second row, first picture). And since we don’t get them in the US, I have no idea what they’re called in English or how to prepare them. The black corn (second row, second picture) was really cool. Apparently it’s sweet, and/or used in desserts. There are also several blocks of mozzarella cheese in that photo. The sales lady thought I was nuts when I asked if it was cheese. Unless it has a rind, I expect cheese to be refrigerated, not sitting outside next to a basket of corn. I gave it a strong side-eye and moved on to the next stall.

Probably the hardest thing to get used to is language-related. Bolivians have a pretty even/flat accent, so I understand their Spanish pretty well. But it’s been a very long time since I’ve had to speak it and my grammar is atrocious. Not being able to speak clearly is frustrating, but what’s really, really hard to deal with is when people make fun of/tease you to your face, because they think you don’t understand what they’re saying. The majority of the time, they’re not being malicious – you are as much of a curiosity to them, as they are to you. But it still stings, especially because the only thing you can really do is grin and bear it. Confronting someone who does this can lead to all sorts of misunderstandings and issues, so it’s better to remain quiet and move on (and then, if you need to, cry at home where no one can see or hear you).

 

(P.S. I’m totally allowed to use cheesy Wizard of Oz references because I’m originally from Kansas and cut my teeth on that movie.)