Revolutionizing Health- A study in Complexity

Envío team

It is often said in Nicaragua that the revolution's health care system has not only fallen into crisis but that its model was unrealistic from the outset. Such criticisms demonstrate little appreciation for the fact that eight years is a very short time in which to revolutionize a health care system. While there are clearly problems, their causes are complex and should not be reduced to that of a faulty conception without further examination. Among the causes, two are foremost: 1) the weighty inheritance of the values and behavioral norms of the Somocista model and 2) the US war against Nicaragua.

In these pages envío offers a mosaic of elements that contribute to a better understanding of the health problematic in Nicaragua.

The Somocista "health system":
Chaos, elitism and charity

For many years the Nicaraguan population’s health was in the hands of two types of people: the private doctor in urban areas and the "curandero," or traditional healer, in the countryside. In extreme cases, society responded charitably so that free health care began to be provided in some places. T a vast pharmacy of medicinal leaves, roots, powders and secret potions he pill bottle and the hypodermic needle were the doctor’s main tools, while the curanderos had at their disposal, the efficacy of which peasants trusted because the secret recipes had been passed down through generations.

In the days of quinine and wormseed oil (the latter an herbal treatment for intestinal parasites) during the 1940s, Nicaragua was introduced to the concept of environmental sanitation and preventive medicine by Dr. Molloy, of the Rockefeller Foundation. The National Hygiene Laboratory was founded to manufacture vaccines and do laboratory examinations. Little by little these new practices were expanded.

The Somoza government, in power since 1934, was never particularly concerned with going beyond minimal public health care. Public health was the responsibility of the various foundations and charity organizations that administered the few scarce resources given them by the state. Not until 1957, 70 years after Germany passed legislation on health insurance, was the Nicaraguan Social Security Institute founded. Even then, this new institution only served Managua and León, and covered only small sectors of the population. In 1978, a year before the overthrow of the dictatorship and 21 years after social security was established, the system only covered 16% of the economically active population and 8.4% of the total population. Of the latter, only 30.7% worked in the productive sector; most of the rest were bureaucrats in the Somoza system.

The health protection given to productive workers was simply a means of assuring an adequate labor force to maintain agroexport production levels. The sole objective was the fastest possible recuperation of the ailing worker in order to return him or her to productive activity at the lowest possible cost.

The most notable characteristic of the Somocista health system was its disorganization. More than 24 institutions were involved in health service management. Among them were the Ministry of Public Health, responsible for planning and direction; the Social Security Institute, financed in theory by private enterprise and the government (though in practice it was left to the former, because the Somoza government ended up 200 million córdobas in arrears for its monthly quotas to the system); and the National Board of Social Assistance and Prevention, which received almost all of its funds from the national lottery for work oriented toward "the poor."

Public health services were marked by a paternalistic conception of well-being as charity. What little preventive medicine existed was completely apart from any integral health plan. Health policy was merely curative, especially problematic in a country like Nicaragua, where three fourths of the population suffers from intestinal parasites, an illness easier to prevent than to cure.

The middle and upper classes had their own health centers and private doctors, and went abroad to solve their more serious health problems. The supply-demand relationship that dominated economic relations also governed doctor-patient relations. In this way a doctor caste was created based on the lucrativeness of the profession, and small private practices abounded, especially in Managua. The system was conspicuously elitist: it is calculated that more than half of the health professionals served only 10% of the population: those with the resources to buy health care in the "medical marketplace."

In terms of available medical attention, the gap between city and countryside became ever greater. A large part of the peasant population was obliged to travel 50, 80 kilometers or more to the closest city, because there were no health centers of any kind in the rural areas.

US influence was strong in the health field, as in many other areas of Nicaraguan life during the Somoza era. On many occasions the plans were a carbon copy of those designed in the United States or were brought directly to Nicaragua by US technicians. And some were designed not only to heal the sick. Birth control or sterilization campaigns and other work in rural zones where the Sandinista guerrillas were active—such as that of the Rural Community Action Campaign (PRACS), which conducted health programs in Nueva Segovia, Estelí, Madriz, Matagalpa and Jinotega—had clear counterinsurgency objectives.

In 1979, there were only 189 primary care units in the whole country, and only 1,311 doctors, more than 80% of whom worked in urban areas. Statistics of the Somoza regime cite the infant mortality rate at 42 per thousand live births, but the actual rate was much more alarming: 120 per thousand. Such appalling infant mortality was the product of a lack not only of preventive programs in the health field, but of other institutions to care for the youngest children. In 1979 there were only 9 day nurseries in the country, of which 8 were privately run. The churches belonging to CEPAD (Protestant Committee for Aid and Development) ran a total of 12 kindergartens. Over 80% of the infant population suffered some degree of malnutrition, and illnesses like measles, whooping cough and diarrhea were the principal causes of death for Nicaraguan children. This was the situation when the revolution came.

Principles of the new health system and its first achievements

Only 20 days after the triumph of the revolution, the new government created the Single National Health System (SNUS) to integrate the two dozen different institutions operating in the public health area. The goal was to create the organizational basis to improve people’s general health, extend health services to the whole population and overcome the conception of health care as strictly curative and based solely on visits to the doctor and consumption of medicines. There was also an effort to ration scarce resources, lower costs and avoid unnecessary duplication of services. The effort, in short, was to put the chaos in order, to create new policies and new principles.

From the very beginning, health was one of the revolution's top priorities. SNUS had six guiding principles:

1) Health is the right of all and the responsibility of the state.
2) Health services should be accessible to the whole population, with priority given to the mother/child relation and to workers.
3) Medical services have an integral character: both individuals and the environment are to be treated.
4) Health work should be carried out by multidisciplinary teams.
5) Health care activity should be planned.
6) The community should participate in all of the health system's activities.

With these principles, the effort to overcome the old disorganized, elitist system got underway. In 1980 health care was regionalized, following the same logic that would be applied three years later in the regionalization of the government apparatus. This consisted of executive autonomy for the regions, based on a coherent focus, norms and overall control provided from the central level. Resource distribution and handling would take place at the regional level, which could respond with more speed and flexibility than the central level. Since the system’s objective was to serve the whole population, efficiency and flexibility became basic objectives from the outset.

This regionalization led to the creation of different levels of service as well. At the lowest level was the health post and at the top the hospital, whether in Managua or in the regions.

Hospital treatment, the central preventive medicine laboratory and the training units are centrally supervised, although these same structures function at the regional level. There are now 30 hospitals in the country, four of which—those specializing in dermatology, psychiatry and rehabilitation in Managua, and tuberculosis in León—are for extended treatment. Only two of these hospitals were built after the revolution.

In the new reorganization, "health areas" were defined as communities of 20-30,000 inhabitants within precise geographic limits. These would be attended by a health center, the health system’s basic unit and the fundamental unit of primary care. Each such area is further divided into sectors of approximately 3,000 inhabitants, attended by nurses' aides and health brigadistas, either mobile or operating from a health post. It is on the basis of this overall strategy that Nicaragua proposes to meet the challenge launched by the World Health Organization to third world countries to provide "health for everyone by the year 2000."

This primary care level is what serves—or should serve—the greatest number of people, and is—or should be—the appropriate filter for determining which patients should receive specialized treatment in the hospitals. It also falls to the health center to develop the necessary programs to protect the environment within its designated territory.

The health center is also assigned a number of other tasks, including health education, the application of preventive measures such as immunizations and environmental and occupational safety, and the early detection of diseases such as malaria, tuberculosis, venereal diseases and others specific to the given region.

The policy of involving the community in primary level health programs such as vaccinations and environmental hygiene has been decisive in the area of preventive medicine. Without the participation of the voluntary brigades, much of what has been accomplished in these years could not have been initially carried out, much less maintained.

As mentioned above, the health plan gave priority to two sectors—mother/child and workers. Attention to the mother ranges from prenatal to postpartum care, and includes gynecological control for cancer detection. Attention to the child includes periodic weight measurement and massive vaccination campaigns. Oral Rehydration Centers (UROs) were created in 1980 to give effective treatment to the dangerous infant diarrhea syndrome.

Within this new structure, the health picture changed dramatically. By 1986, according to Ministry of Health figures, the 189 primary care units in existence in 1979 had become 606. Of those, 468 were health posts, smaller than health centers and in the more isolated zones. The number of doctors increased by 58% and of nurses by 211%. Medical consultations went up 300% and infant mortality dropped from 120 per thousand to 69. Life expectancy is now 63 years compared to 53 at the time of the revolution.

The Popular Health Campaigns began to function in 1981, especially for massive vaccination programs. Grassroots participation in these campaigns eradicated polio, with no case reported since 1983, and reduced malaria by 50% in 1986.

The other important field of battle has been that of diminishing infant mortality caused by diarrhea. In Nicaragua, 75% of infant deaths in the first year are the result of dehydration caused by diarrhea. In the first half of 1986, 163 infants died of diarrhea in Managua; in the first half of 1987, the number was 116, almost a third less. In addition, gastroenteritis fell from first to third place on the list of mortal diseases. In this the UROs have been decisive.

The health education courses given to volunteer brigadistas and auxiliary staff in health posts and centers are a fundamental pillar of primary care. Since 1981 there have been 3,910 workshops on polio. In 1986 alone there were 1,370 health assemblies, grassroots forums in which community health problems are discussed and participant initiatives to resolve them are studied.

Is the revolutionary model in crisis?

After more than eight years of revolution, the advances in the health field are enormous. Equally enormous, however, are the problems that remain to be resolved. Long lines at the door of the health center, interminable hours in the emergency waiting room at the hospital, appointments with specialists for "some time four months from now," and urgent operations that can only be done six months after they are programmed indicate for some that the model is in crisis and that health as a priority of the revolution is nothing more than a nice dream.

What exactly happened? Analyzing the problem more carefully, it becomes clear that the model itself is not what’s in crisis. Its foundation and its policies are still valid, as are the structures of primary and secondary care, the health coverage designed for the rural areas, the mother/child priority and the preventive medicine campaigns. Furthermore, the autonomy of the regions in planning, programs and distribution of resources has been consolidated.

Reality is always more complicated than plans or dreams. To go from a situation of little or no care and concern, where death is seen as fate or "what God made us for" and life is a continual risk, to one in which health and life are a right for all and a duty of the state is not an easy voyage. It creates rising expectations among the population and ever expanding responsibilities for the state.

In Nicaragua the demand for more and better health care comes up against a serious scarcity of resources. From this perspective, what has entered into crisis is not the model but its administration. On top of it all, the war has placed a nearly unbearable burden on what would otherwise be the "normal" crisis provoked by revolutionary change in the health field. It goes without saying that administration in peacetime is not the same thing as during a war. It was one thing to administer health care in 1981, when the war was just beginning, and another to do so now after seven years of a war aimed at wearing down an already weak country.

Even in 1982 the counterrevolution’s effects were not yet being felt in health. It was in 1983, when the war became a White House priority, that it began to have a strong impact. Since then the development of projects has been slowed, as has been the capacity to respond to the population’s demands.

Health ministries, criticized almost universally for inefficiency due to their massive bureaucracies, become excusably inefficient when resources are scarce. It is nothing less than heroic to care for a thousand patients in a hospital designed for 400 that has seen its personnel taken off by the war, is short of cotton today and could be without anesthetics tomorrow. A professional consciousness that responds with such daily heroism is not built overnight.

Structural problems must also be taken into account. In Nicaragua the medical sector was never characterized by its discipline, bedside manner, careful diagnosis or set hours. One of the major contributing factors to labor indiscipline is the fact that 85% of the health workers are women, in many cases heads of family with several children. This problem could be substantially alleviated by constructing childcare centers in the hospitals.

It also used to be common for paying patients to be treated by "their" doctors in state installations using public resources. Such practices created a set of habits that have not automatically disappeared with the putting in place of a new model. "It isn't that the traditional physicians have a bad attitude toward the revolution," Health Minister Dora María Téllez points out. "But the habit of doing things according to the old routine prevails among many."

As already mentioned, physicians were a rich and privileged caste under the Somoza system. The current economic crisis not only limits the acquisition of instruments and other resources, but shatters the prospects of wealth for traditionally trained doctors. The material incentives to which many could aspire have shrunk substantially. In many cases, those incentives guaranteed some level of professional efficiency. A doctor's salary today in the public sector is some 800,000 córdobas, at a time when a pound of good beef costs 25,000 and a liter of milk 2,500.

The current situation demands a supreme effort on the doctor’s part. To go from specialized treatment of a limited number of patients to mass treatment, from "luxury" care to modest care with a paucity of resources, from a paternalistic conception of health to one of rights and duties, from a practice characterized by the doctors' absenteeism to one in which their presence is urgently required, from a consumerist scheme to one of rationing is rough on everyone. Turning all this on its head is a tremendous challenge.

Between 1979 and 1986, 646 doctors and 886 health technicians left Nicaragua, further aggravating the problems facing the health sector. In part to cover the vacancies but particularly to implement the new health policies, the revolutionary government prioritized medicine as a career. At the beginning, however, given the logical desire of rapidly increasing the number of physicians, students were not selected stringently enough. Many of those students, who are today practicing physicians, lack the sense of professionalism that could enable them to confront the challenges of this process of change. The image of the doctor as privileged and the criterion of individual enrichment have not yet disappeared among medical students, who often approach public health in a routine way, still aspiring to a private practice with air conditioning and a secretary.

Despite everything, the young doctors who are adapting to a survival situation and who have gone through their studies in the midst of the country's hard reality are beginning to make their weight felt. Of the 377 doctors who were in the second graduating class after the revolution (the 1980-86 cycle), half participated in military defense tasks for a minimum of three months at a time and 100% participated in production tasks. Since 1986 the criteria for student candidate selection have been restructured to demand better quality and an attitude of service.

From all sides a new concept of health is pressuring the old with its own dynamic. The new model being born, whose principles and policies are valid, is limited by the scarcity of human and material resources, its own newness and the still incomplete way in which it is being taken up. A health care service that really gets to all Nicaraguans equally can only be built on a model such as this one, but even so it can only develop slowly.

The contras: Hazardous to your health

"In Nicaragua," Health Minister Téllez has often remarked, "the primary causes of death are diarrhea among children and the war among adults." According to figures presented by President Daniel Ortega on June 24, 1987, 43,176 people had been killed, wounded or kidnapped by that date. Of that total, which includes counterrevolutionary casualties, 22,495, or a little more than 50%, were deaths, including 2,327 women, 2,210 children, 179 teachers, 52 doctors and 15 nurses. In other words, 1.35% of the Nicaraguan population have been direct victims of the war, and 0.7% killed. Those figures, which are by now much higher, did not include the nearly 11,000 war orphans and more than 250,000 displaced peasants.

Many of the wounded have been left disabled in one way or another—blinded, amputeed, brain damaged, etc. Each case represents a high human and social cost. "If before we had 100 córdobas for health, now part of this must go to care for the war wounded, to prevent their death," says Tellez. "The war is a new illness we must treat."

The counterrevolutionary aggression also affects the Nicaraguan population’s health in more indirect ways; it is a cause of malnutrition among the peasantry, especially the children, since massive relocations disrupt planting and harvesting and the war makes the compensating distribution of basic foodstuffs to the new settlements more difficult.

Various indicators demonstrate how the war and the economic crisis provoked by it have affected the health situation in the war zones. In 1984, for example, the number of primary care units dropped from 501 to 456 and the number of physicians from 2,081 to 1,468, while infant mortality due to diarrhea and other preventable diseases like measles climbed. The massive population relocations—200,000 peasants were relocated in 1986 alone—and troop mobility have brought about epidemic outbreaks of malaria and dengue and the resettled population frequently suffers health disorders at the outset due to the lack of drinking water and latrines. In regions relatively unaffected by the war, malaria dropped 62% in 1985 compared to 1984; in war zones it rose 17%. Measles increased throughout the country after 1984, but mainly in Matagalpa, due to population displacement. In 1984 there were 153 cases in that zone; in 1985, 956.

Massive programs implemented since the revolution to deal with malaria, tuberculosis and rabies among the peasant population have been affected by the war. To implement such programs, brigadistas had to go into the sparsely populated mountains and give vaccinations house by house and community by community. This work has been curbed by the fighting and the continuous harassment health workers suffer at the hands of the counterrevolutionaries. Since 1983, the most effective year in eradicating and controlling these three diseases, they have begun to reappear in the war zones.

The destruction of the health infrastructure is another concrete effect of the contra war. Reagan's "freedom fighters" have burned or otherwise destroyed 60 primary health units, at an approximate cost of five billion córdobas, affecting some 300,000 people.

Managua: The biggest crisis

Managua is perhaps one of the world's most difficult capitals. It has been called an anti-city. Over a third of the population lives in the wide swath that arches out over 100 square kilometers on the south shore of venomous Lake Managua. It now has an annual growth rate of about 7.4%, of which nearly half is caused by the constant inflow of peasant migrants escaping the war. From 400,000 inhabitants in 1969, Managua now has close to 1.5 million. Its disorganization, lack of planned expansion, particularly following the 1972 earthquake, and insoluble geographic limitations, which range from earthquake faults to eroded lands and a contaminated lake, make super-populated Managua one of the major problems the revolution faces today.

The rapid and constant population increase complicates everything—food supply, transportation and, of course, health services. Despite everything, the revolution opted not to make Managua a priority, but to direct its best efforts to the historically ignored countryside. This was also its decision in the area of health, and it has provoked a major health crisis in Managua. Care is deficient and coverage insufficient. Getting sick in Managua today brings on two pains: the illness itself and the uncertainty about how and where to get treatment.

The seven hospitals in the capital before the earthquake were designed to attend a population three times smaller. At that time, six of them were concentrated in the center and western part of the compact city, and so was the majority of the population; the largest neighborhoods were Altagracia, San Judas and Monseñor Lezcano. The earthquake altered both the density and geographical distribution of the population. Today it is spread out over a long curve that stretches around the earthquake ruins at the edge of the lake, and 60% of it is now found on the eastern side of the haphazard city. This population redistribution, however, was not accompanied by a redistribution of services, and today the exaggerated curvilinear organization of the city makes any restructuring difficult.

The new health model designed by the revolution is efficient when each level fulfills its role. A cornerstone of the system is that the health centers function well, since it is there that the first diagnosis is made and the first treatment given, and there that it is decided whether the complexity of the illness requires referring the patient to the hospital. It is a perfectly rational design, but the lack of human resources, both in quality and quantity, has made it irrational.

From the outset, the health centers—particularly in the cities and above all in Managua—were undervalued by both the medical profession and the system that created them. Worn-out doctors or those "punished" for indiscipline were assigned to them. Turnover has been enormous; it is rare to find personnel at this primary level with more than two years' experience. Created to absorb the "first blow" of the huge health demand, this level thus turned into a recycling center, sending patients, whatever their ills, off to the hospitals. Getting no satisfaction from the consultation at the center, patients soon felt themselves perfectly within their right to ignore it, and began turning up directly at the hospitals. The result was that an emergency room attendant was as likely to find people in line with a headache as with a brain tumor.

Berta Calderón Hospital—the women's hospital—is one of the most resistant to the excessive demand. Created for 150 beds, it is now working with 260 patients at a time, often with two or three women in the same bed. This obliges the medical team to release patients as soon as possible—and sometimes sooner. In normal conditions, this hospital can attend 8 births a day in each delivery room, but the real average is three times that: 25 births in each. The time pressure is insufficient for proper care.

The fact that there is only one women's hospital in all of Managua creates other serious problems as well. Located at the extreme western end of the capital, women from the eastern neighborhoods must travel long distances once they go into labor. Given the difficult transportation situation, they often give birth on the way, multiplying the number of times in which police vehicles—often the only ones around at night, since they are on patrol—are converted into ambulatory delivery rooms. A group of police officers have been in training for some time to be able to fulfill the role thrust on them as "emergency midwives."

To so many limitations of an absurd urban infrastructure is added the carelessness of insufficiently conscientious medical or paramedical personnel. The media have aired many cases of professional irresponsibility and the Minister of Health has taken a firm hand with those to blame. As she expressed it in a lengthy live interview on Radio Sandino in mid-1987:

“Errors in the health sector are expensive. It is the life of the people that is at stake. If it were an error making a shoe it would be less serious because you wouldn't die; your feet would hurt and that would be the end of it. But a bad diagnosis or late treatment is fatal. You can fix a shoe, but you can't revive a dead person. To speak of a dead child, or even 80, doesn't sound as ugly when it’s figures, but is shocking when these children are given names, a father and mother, and have the right to live. We are uncompromising with negligence because it has a high cost and human life is in the balance. All of us who are health workers have to have the perspective that all patients we treat are our brothers, our relatives. At times one loses that human link, but it has to be recovered....”

Another problem that has been a subject of public debate is the organizational failures in hospital administration and the lack of an ethical conscience regarding available resources. In February 1987, Deputy Health Minister Pablo Coca noted that of the 8 billion córdobas that the Ministry of Health receives for medical inputs, 200 million, or 2.5%, have been lost through deterioration, lack of attention to expiration dates or theft. Relatively inflexible customs structures, bad purchasing calculations and defective warehousing conditions are among the many problems, but robbery compounds them. Medicines, sheets, towels, etc., disappear frequently from the hospitals. Low staff salaries and the economic crisis help explain this, but, at bottom, it is clear that eight years of revolution are still too few to change the consciousness of all those in whom individualist habits and a lack of appreciation for social property are so deeply rooted.

Environmental hygiene is a major problem

The conception of health that prevailed during the Somoza period did not take environmental hygiene into account, and thus did little to educate the citizenry. The epidemiological chart of a family or population sector is thus often rooted in a minimal understanding of the relationship between health and cleanliness.

In Managua, the health situation is aggravated by water scarcity, particularly now with the population explosion in the city. In the summer months (October to May), when there’s no rain, a city as full of dust as Managua, with its great expanses of parched rubble, turns into a culture medium for all kinds of contagious diseases. Managua needs 80 million gallons of water a day to supply its population, yet the existing tapped sources only produce 45 million. To deliver greater quantities of water, new and better wells must be dug. Fortunately there’s a good potential supply to assure a healthy population in the future.

The accumulation of garbage is another serious health problem —Managua ends up each day with 300,000 kilos of uncollected garbage for lack of vehicles. The population is still not educated about the need to burn or bury their garbage. Instead, each neighborhood or sector of a neighborhood creates its own "secret garbage dump" and, therefore, its own locus of contamination.

Behind infant diarrhea are the flies that swarm around these garbage heaps. "It is urgent that we find a solution," says Fulgencio Báez, the Health Ministry’s regional director in Managua, "because a garbage collection system to keep the city clean is cheaper than curing the illnesses caused by garbage accumulation." It is calculated that deaths from diarrhea could be reduced by half in Managua if these garbage dumps were eliminated, but the Managua government lacks the resources to acquire new garbage trucks. At this point the solution seems to lie in massive popular education. The media are now engaged in constant campaigns.

As an emergency solution, "health commissions" were formed in April 1987 in different Managua neighborhoods with the goal of involving the population in improving hygienic conditions. The commissions are made up of the health coordinator, doctor and nurse from the sector, as well as a grassroots health educator and local volunteer brigadistas. Their task is to make house-to-house visits to determine where there are people with tuberculosis, malaria, diarrhea, etc. By now there are 5,000 brigadistas in Managua, each with responsibility for 20 houses.

The rural health centers are a real revolution

The crisis of administering the revolutionary health model, especially in Managua, could lead to unwarranted pessimism. To avoid it, one need only look to the results accomplished in the countryside, which are as real as the crisis in Managua, although less visible. Many of these advances in the peasant zones are virtually the first steps in the health field ever taken by the rural population. And therein lies their importance.

One of the most moving examples is in El Cuá, Jinotega, that tiny spot immortalized by Ernesto Cardenal and Carlos Mejía Godoy when they poetically and musically narrated the laments of the "women of El Cuá," victims of the National Guard.

In El Cuá, the jail where peasants were once tortured and killed is today the health center where the local population is treated. For the first time ever, El Cuá has a health institution. During the reign of the Somozas only medicine hawkers or a curandero from a nearby zone ever arrived in El Cuá. Anyone who was seriously sick had to travel 80 kilometers on a dirt road to the nearest hospital in Jinotega.

Health care came to El Cuá with the revolution. Since there was no existing infrastructure, the first health workers had to set up operations in peasants' homes. Soon an 8x3-meter shed was built, divided into several sections that served as consulting rooms, dispensary, hospital, or whatever was needed.

In 1981 a group of foreign doctors working in the area began to push for the construction of a health center, soliciting support from local residents and the coffee growers in the zone. The site they selected was "La Chiquita," a small jail infamous in those mountains as a torture and death center. Alongside the jail, there still stands the avocado tree to which the National Guardsmen used to tie up peasants.

Today, however, the sinister old jail is a "big" health center, or a small hospital, with its own laboratory and delivery room in addition to the consulting rooms. Although the center was not originally meant to handle inpatients, some 20 are treated each month, spending two or three days there. The center has a staff of three doctors, two graduate nurses and ten aides. Although it provides general treatment, the priority programs are maternity-infant care, war wounds and immunization programs. In the first six months of 1987 the center gave 28,000 consultations to the 35-40,000 inhabitants of the zone under its care. Five health posts buttress and complement the services provided by the center, in each of which a nurse's aide deals with pregnancies, mother-infant care and basic consultations: diarrhea, skin infections, etc. These posts receive tuberculosis sufferers and the one in neighboring San José de Bocay also takes in some war wounded.

As have many other zones of the country’s north and central areas, El Cuá has been hard hit by the war. Ambrosio Mogorrón, a Spanish doctor, worked in El Cuá-Bocay until he was killed by the counterrevolutionaries on May 25, 1986; so did the US engineer, Ben Linder, until the contras shot him and two Nicaraguan workmates at point-blank range almost a year later, on April 28, 1987. Of the five health posts, the one in El Cedro has been burned three times and the one in Santa Rosa was destroyed in a separate counterrevolutionary attack. Both later arose again from their ashes; the first was rebuilt in 1987 by veterans of US wars who are now working with the Veterans Peace Action Team. It was dedicated to Ben Linder, his co-workers Pablo Morales and Sergio Hernández and all the martyrs of El Cedro. The health center itself was attacked in 1983, but the contras did not succeed in destroying it, although they did finally destroy its ambulance in their third attempt on the vehicle.

Work has continued, with enormous limitations but also with enormous effort and spirit. Those who work in stark Managua t at times urn their imagination to El Cuá in search of encouragement and motivation.

Breaking the pill culture

Nicaragua has traditionally been a country that consumes a lot of medicines. This reflects the people’s poor health education and the distortion of the doctor-patient relation, the fundamental link to health education. All patients need to feel listened to and cared for by the doctor. It is in that moment that the physician could and should convince the patient of the damage that medicine abuse can cause to health. A massive media campaign could also halt the indiscriminate consumption of medicines, but if doctors' attitudes don’t change, even the best campaign falls on deaf ears.

The Somoza system, like all capitalist systems, was based on consumerism, and the health sector was no exception. Visiting doctors promoting the latest medicines and the big transnational pharmaceutical houses glutted the Nicaraguan market with medicines.

For any pain, six medicines with different names but a similar chemical composition might be prescribed. Competition between the six rather than the demands of the one disease was what reigned in the market. Supply was excessive, demand became distorted and soon the population became accustomed to thinking that health depended on the greater or lesser consumption of medicines and that the more prestigious doctor was the one who most lavishly prescribed them. The doctor who emphasized bed rest, plenty of water and no cokes or coffee for kidney pains was considered not to have treated the patient.

Rather than try to prevent illnesses, the medical profession tended to throw a battery of pills at them. This habit has not yet been uprooted; the more expensive the medicine and rarer its name, the better. As there is no training to understand why one medicine might be better than another, or why none might be better yet, the patient can end up feeling very frustrated by a doctor who tries to impose rational order on the chaos.

There is also a high self-medication rate in Nicaragua. Aspirin, high-powered antibiotics and all kinds of other medicines have been sold—and are still being sold—in supermarkets on the same shelves as buttons and crackers. Ampicillin and vitamin B complex heavy on B-12 are everyone's favorite self-prescribed medicines for whatever disorder, no matter how light or serious. For mental exhaustion or migraine, vitamin B injections; for indigestion of whatever cause, Milk of Magnesia; for any degree of flu, ampicillin by the dozens and for nervous tension, Valium. All Nicaraguans know this, all treat themselves and exchange prescriptions; there’s no difference in authority between a market seller, a peasant from the interior, a computer technician or a doctor of law.

It is the duty of any government to rationalize medicine consumption. In Nicaragua this duty becomes more urgent because of the restrictions imposed by the war, which limit the foreign exchange available to import pharmaceutical products.

Until 1984, 80% of Nicaragua's medicines came from the United States. With the economic embargo, the country was obliged to diversify its markets for all import categories, medicines included. At that point the Ministry of Health prepared basic lists, taking into account the shortage of foreign exchange and the country’s epidemiological characteristics. In 1984 there were 667 products on the list; in 1985 it was reduced to 475, in 1986 to 390, and in 1987 to 350.

Of these, around 100—ampicillins, analgesics, anti-inflammatories, etc.—are produced in Nicaragua's 28 pharmaceutical laboratories, of which only two belong to the state (Solka and Laboratorios Populares). The Ministry of Industry provides the raw materials to both the state labs and the private ones, according to their production plans. Since the embargo, this raw material, and the bottles, capsules, etc., come from Spain and other European countries, the socialist countries, Mexico and elsewhere. More than 60% of all medication is still imported and the need to import even the containers renders it more difficult for products made in Nicaragua to cover the national demand.

The Ministry of Health acquires the nationally produced or imported medications and centralizes their distribution through the 1 state and 28 private distributors that supply the 278 pharmacies in the country. Of these pharmacies, 138 are in Managua, 125 of them private, 4 public and 9 in the hospitals themselves. Currently 30% of the health ministry's budget is dedicated to importing medications, a budget that in 1987 was only $30 million. For comparative purposes, cotton, which is the country's second largest export crop, brought in $40 million last year.

Until March 1986, the Ministry of Health did not charge for medicines in the state-run pharmacies or the hospitals. At that time it decided to tag on a small price, not only to recuperate some of its investment but also to control the unwarranted use of medicines. It later established that a prescription would be required for the sale of 253 of the 390 medicines from the basic list. At the beginning the measure created tensions, because it affected the population’s old habits and was not accompanied by any prior public explanations. More recently, however, positive results can be observed.

Bringing back traditional medicine

Traditional medicine was not given any special attention before 1985, but with the scarcity of medicines there was an awakening of interest that converged with that of international organizations interested in supporting projects to recover this practice, particularly for treating benign illnesses.

The first project of this sort was launched in Estelí (Region I) as a strategy designed to improve primary care and move toward self-sufficiency. For three years, Bread for the World, a nongovernmental organization based in France, supported this project with $200,000. The European Economic Community, MLAL from Italy and Oxfam US also donated money and vehicles.

The project began to take shape during the fifth Student Days of Science and Production in 1985. During these annual fairs secondary students show development projects they have designed that are appropriate to the Nicaraguan reality. On this occasion, 845 students and 61 professors of the natural sciences presented the results of their visits to 26 municipalities, where they conducted 3,000 interviews. With the direct collaboration of the curanderos in these zones they put together the first census of herbal resources in the country. They classified some 325 medicinal plants, 72 of which are already identified as "clean" plants, that is, with proven results.

Currently operating in Estelí is a botanical pharmacy that works with 28 medicinal plants, including garlic, eucalyptus, mint, mango and guava. During the 1986 coffee harvest, these began to be successfully used to treat the pickers’ diarrhea and the bronchial-respiratory diseases. In the El Cuá health center there was a festival of herb healers in July 1987, as a way of recognizing the services they provided the community.

In the short term, the objective is not to industrialize traditional medicines, but to recover the lost habit of turning to plants to cure the simplest diseases, a habit displaced in the cities by pharmaceutical consumerism. In 1987 the Ministry of Education incorporated studies of the medicinal properties of plants in sixth-grade courses. Nurses and doctors also study this material in the course of their medical major.

A survival health policy

"We aren't thinking about medical care for a developed country but about minimal care for our population; however, we don't even have the resources to cover all the medicinal list, maintain our hospitals and have all operating rooms and recovery wards functioning well. We have to create a survival economy." This was expressed by the President of Nicaragua in the closing ceremony of the 11th Congress of the National Students' Union of Nicaragua in August 1987.

When the revolutionary government put a priority on health in 1979, the dominant outlook was to reconstruct a country devastated by the war of liberation from Somocismo and whose capital still wore the scars of the 1972 earthquake. When the hospitals were specialized in 1981, the perspective was to give more and better treatment to the capital's population.

The war and its growth year after year destroyed both of these possibilities. The resources destined to defense meant limited resources for building new hospital units and the specialized hospitals could not support their specialization given an overwhelming demand from an unexpectedly burgeoning population. The logic of specialization also responded to a society not only at peace but also more developed than Nicaragua's. The war imposed the logic of emergency and of survival, which
demanded a new, much more realistic proposal.

The 1987 plan has been a cornerstone for turning the specialty hospitals back into general hospitals, leaving only one specialized center: La Mascota, the children's hospital. Not all medical personnel agree with this decision. Some see it as a retreat and others have become accustomed to working only in their specialty.

This change requires that health centers efficiently fulfill the primary and general care role for which they were created, which in turn requires that enough quality doctors, nurses and auxiliary staff be assigned to these centers. As a new measure, 80 doctors were sent to Managua in 1987 to carry out their social service as "territorial doctors." The communities to which they are sent, in coordination with the sector's health center, takes responsibility for finding them consulting space—in a private house, a garage, or whatever—to give medical attention to the community. Thirty Managua neighborhoods in which illnesses have proliferated due to unhealthy conditions have been designated as priorities for this initiative, and up to now 50 such consultation rooms are already functioning, with excellent results.

Another measure to impose order in some of the capital’s health chaos is the use of appointment schedules in the health centers. Up to now, lines began to form at the doors of these centers starting at 5:00 in the morning, even though the consultations do not begin until 8:00. It was very common for people to spend three hours or more waiting their turn. This happened because everybody knew that with few doctors, they wouldn’t get the opportunity for their consultation if they didn’t wait in line. To create a habit of discipline and confidence that they would be treated, the new habit of appointments was established.

The so-called Economic Brigades—the trade unions' answer to the permanent crisis situation the war had created in the country—began to function all over Nicaragua starting in 1986, with the goal of raising efficiency in the different productive areas. A similar effort was made in all the hospitals in Managua and the regions. In November 1987 there were already 200 of these brigades, in which over 5,000 health workers participated, from doctors, anesthetists, nurses and lab workers to drivers and even menial workers. The fundamental objectives proposed by the brigades were to eliminate the backlog of operations, improve the general patient care and better maintain the different health facilities.

In the Berta Calderón Women's Hospital, which also does ophthalmologic consultations, for example, a backlog of 180 gynecological operations and 5,000 ophthalmologic operations had accumulated by May 1987. When the brigades began there, they only included 40% of the personnel, but in the ensuing months they reached 90%. Virtually the whole staff has buckled down to work extra hours and weekends, putting greater emphasis on daily tasks and thus improving the whole gamut of health care. With this effort, up to 10 of the pending operations were performed daily in the different Managua hospitals. The brigades have also attacked the inertia into which some sectors of the medical profession had fallen.

But it’s not only inertia. Many of the difficulties in surgical operations originate with the scarcity of technical resources. Over 70% of the medical technology employed in Nicaragua is from the United States and was close to paralyzed following the economic blockade for lack of spare parts. Technological changes are possible but are always complex and slow. The surgical rhythm has been interrupted often by the lack of anesthetics or sutures or some other more sophisticated instrument. Air conditioning in surgery rooms has also been affected by the lack of spare parts and surgeons must be careful to prevent their sweat from falling on the open wounds of the patients they are operating on.

The advantage of all these difficulties is that it inspires the imagination to find new solutions. For example, deliveries were traditionally considered the "official responsibility" of the hospital the women in labor managed to get to or of the private doctor providing home care. Empirical midwives, as they are called, were not taken into account in planning, even though there were many of them.

In 1982 the Health Ministry began training programs for these midwives, thus recovering the value of their secular practice. The program includes intensive training courses and follow-up advisory sessions where they have their practice. UNICEF supports this program by providing each midwife with the minimum instruments she needs for her work: a bag with cotton, pincers, recipients, towels, etc., which are replaced as necessary.

In fact only 45% of the births in Nicaragua are currently attended in a health institution. Of the 55% attended at home, 75% are the responsibility of these "trained empirical midwives," as they are now called. Even in the capital, more than half of the deliveries are attended by these knowledgeable women.

To adequately coordinate the three sectors—private, state and military—that the population’s medical attention depends on is another goal to respond to the current survival situation. The revolutionary state has never proposed doing away with private medicine, even though Nicaragua has never had wide-ranging private clinics as other Central American countries do. Private medicine today represents one road to solving the problems resulting from the congestion of demands in the public sector at least in part. For those who can pay, this road should remain permanently open. The majority, however, cannot pay. An operation, even one of the most simple, costs five to ten times today’s average monthly salary. Some 90% of the physicians currently combine public treatment with consultations in their private offices. They do it for economic reasons and also because the very fragility of the public heath system, incapable of effectively covering the whole population, creates this demand and justifies the supply. "Mixed medicine" thus has a predictably secure future.

To consolidate all these measures and initiatives—whether large or small—to rationally control the scarce existing resources, prevent renewed outbreaks of epidemic diseases, slow down deterioration of the health infrastructure due to the war and struggle against the deficiencies not caused by the war, are the enormous health care challenges that the revolution faces in the coming years.

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