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┬ácountry’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!


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.