Health: Taking AIDS Seriously
Located in the eastern half of the city, Bello Horizonte is one of Managua's traditional working-class neighborhoods, the site of frequent combats during the 1979 insurrection. The hub of the barrio is a small park area surrounded by a movie theatre, several pizza joints and cantinas, and other small shops. Most evenings the area is crowded with people meeting friends, looking for something to do or simply hanging out.
The night of December 1, an unusual element was added to the evening goings-on as members of the Sandinista Youth passed out condoms and information on AIDS, as a kick-off to a nationwide anti-AIDS campaign.
In nearly ten years of revolution, Nicaragua's health care system has concentrated on massive health campaigns designed to deal with diseases long under control in the developed world—polio, malaria, infant diarrhea and the like. But while AIDS may seem less than top priority in a country ravaged by war and underdevelopment, the health authorities in Nicaragua have taken it very seriously indeed.
AIDS comes to Central AmericaThe first AIDS cases reported in Central America were in 1985 and involved prostitutes servicing US soldiers at military bases in Honduras. The second cluster of cases appeared among prostitutes at US bases in Guatemala. The World Health Organization reports 164 cases in Honduras, 66 in Costa Rica, 39 in Guatemala, 32 in El Salvador and 6 in Nicaragua. The first two official deaths of Nicaraguans from AIDS were recorded in 1988. A young man in the southern city of Rivas died in late August, and in November, at a Ministry of Health (MINSA) seminar, MINSA officials revealed the September death of smother young man who had been sent to Bulgaria on a scholarship in 1985.
The Bulgarian health authorities, who test all incoming students for AIDS, sent the young man home when they learned that he was infected with the HIV virus, but he never reported the case to MINSA upon his return. Up until the very end, his family had no idea that he was dying of AIDS. After making the rounds of various health centers in Managua and being treated for malnutrition and tuberculosis, among other things, he was finally correctly diagnosed. At the MINSA seminar, the six other cases of AIDS were reported. That attitude was short-lived.
Facing realityIn the fall of 1986, even before any cases were reported, the annual Nicaraguan-US health colloquium in Managua featured several presentations on AIDS. Some participants were initially hesitant, feeling that AIDS might not be an appropriate or relevant topic for Nicaraguans. Nicaraguan health workers who had participated in the first colloquiums, however, made it clear to the US delegation that, as health professionals, they wanted and needed to deal with it.
A proposal came out of the 1986 colloquium, calling on the Ministry of Health to train popular health educators to address the whole question. "We began to organize people within the homosexual community. There really isn't a homosexual liberation movement here, and many of us are still dealing with internalized repression. We began to work with groups of homosexuals who were interested."
That's the assessment of Rita Araúz, a Managua-based psychologist who works with MINSA on an AIDS advisory team. "We and the people at MINSA," she said, "are very clear about the fact that the only thing we can offer the population is education, because the treatments that are available at this stage are extremely expensive and therefore effectively out of reach. Obviously, given the situation we're facing here, AIDS is not a priority. But, nonetheless, MINSA has been very open and sensitive to dealing with the issue. There's never been any problem in that sense."
According to Jeff Gates, a US nurse who works with AIDS patients in New York and has visited Nicaragua many times since the early 1970s, the approach here, which is unique, was that “we need an integrated gay community in order to draw on their support and information and advice.... I know someone who's gay and works in the Ministry of Health, and I know someone who I think is gay who works with the cultural workers, and I know a guy who works in a cooperative where they all wear scarves and earrings and I swear to god they've got to be gay....”
The National Commission on AIDS, formed in 1987, is made up of epidemiologists and psychiatrists. The commission works under the auspices of the Ministry of Health's Department of Infectious Diseases, and is advised by a four-person technical team. Dr. Alba Alvarado, head of the epidemiological team from MINSA, which is tracking AIDS in Nicaragua, describes MINSA's work with the population as falling into two distinct categories: prostitutes and homosexuals. The work with prostitutes has been through the rehabilitation program being carried out under the auspices of the Antonio Valdivieso Ecumenical Center.
"Our objective was to educate them about the disease, about necessary preventive measures and so forth. We didn't want to be aggressive, but rather tried to persuade them of the necessity of testing. We don't think coercive measures work, and that has never been MINSA's policy in any case. Of all the women tested from the rehabilitation program, about 200, not one positive case was identified. We have to take into account that this sector of prostitutes does not tend to work in the upper classes, but in their own barrios, with regular customers. We haven't been as successful in working with the 'clandestine,' higher-class prostitutes who serve more of a foreign clientele."
According to Alvarado, MINSA has worked much more closely with the homosexual community, doing a number of informal talks and workshops. "Initially that community's attitude was that people didn't want to have anything to do with AIDS, so it was a whole process of persuasion—they were interested in workshops and all, but didn't want them to be a MINSA project."
The technical advisory team had already existed in embryonic form, but really took off in the wake of the first Nicaraguan-US Health Colloquium. MINSA's goal is to test 80% of those in the groups at risk (homosexuals, prostitutes and sexually active young people) Managua.
According to the FSI,N daily, Barricada, 20,547 tests have been done to date—not even 5% of the sexually active population. Twenty-seven cases have proven positive, the majority of them foreigners working in Nicaragua. All but three of these foreigners have left Nicaragua in the normal course of events. While some countries were notoriously slow in responding to the threat of AIDS, Nicaragua took relatively quick action, surprising some observers who thought that the machismo and homophobia that permeates much of the culture might well color any government efforts to deal with the disease. And in fact, the very first public mention of AIDS in the country’s daily newspapers had emphasized its incidence in and around US bases in Honduras and contained barely disguised contempt for the victims, attempting to convey the impression that Nicaragua was somehow exempt from the problem.
“Not every gay man in Nicaragua has taken advantage of the testing system,” says Jeff Gates. “They’re waiting, they don’t want to take the risk, and just as in the US, a lot of them don’t want to know. It’s an individual decision whether or not to be tested; you do have the right to be tested or not. That’s amazing, here, that they’re doing that.”
Education: The problem and the keySince Nicaragua’s campaign against AIDS hinges on prevention, a high level of education and consciousness-raising will have to take place. As psychologist Araúz says, “We have to teach people to eliminate the risks of infecting themselves, and this is very difficult to do, to talk about such intimate things as someone’s sexual practices in a society where much of that is still taboo. It’s very difficult work, but it has to be done.” The Ministry of Health has approved plans for a Center for Sexual Education and Orientation, an independent institute that would serve as an information and informal drop-in center to address a number of issues, including AIDS. One dream is to have a 24-hour hotline operating, at least on the weekends. The center currently is on hold due to lack of funding. (The San Francisco-based Nicaraguan AIDS Education Project is channeling donations.) MINSA plans a national educational campaign for 1989, to be concentrated in Regions III (Managua and the surrounding area), III (Carazo-Granada) and VI (Matagalpa-Jinotega).
Mercedes Tenorio, who works with MINSA on the AIDS prevention campaign, says they hope to test 8,000 people this year. MINSA plans to concentrate its educational efforts in secondary schools as well as universities and technical training schools, and will emphasize the importance of using condoms, which MINSA gives away during their workshops at different sites. Condoms are also easily, and inexpensively, obtained in most pharmacies in Managua and other cities. The UNICEF representative to Central America, Dr. Agop Kayayan, recently reported that UNICEF will be funding sex education programs throughout the region. Kayayan said that in every Central American country except Nicaragua, there are children who have AIDS. The media, too, has an important educational role to play, and recovered fairly rapidly from its initial knee-jerk response.
Barricada published an editorial in September 1988 warning against hysteria and misconceptions about AIDS, calling them nearly as grave as the disease itself. The editorial stressed the importance of prevention and warned that "the virus is extraordinarily democratic: [attitudes such as] homophobia, racism, and sexism are completely useless in containing it.” Barricada has also published a number of informational articles explaining how AIDS is transmitted and what measures can be taken for safer sexual activity. Most young people who become sexually active in Nicaragua have had little straightforward sex education and, consequently, little idea of the risks they may be taking. More public attention focused on AIDS may well have the added benefit of increasing people's general level of knowledge about sexually transmitted diseases and the ways to prevent them. There is still a tremendous amount of work to be done, as was made clear by a three-part series on prostitution carried in Barricada in late 1988. When asked by the reporter what steps she was taking to protect herself from AIDS, "Isabel," a young prostitute, replied, "People here don't have that, that's a gringo problem, so I just make sure to never go out with foreigners."
Health workers themselves could also do with a bit of consciousness-raising. In both Rivas and Managua (where the two AIDS deaths occurred last year), MINSA authorities report that the reaction of some of the health workers bordered on hysteria. And at the MINSA seminar in November, Dr. Leana Vega reported that a number of staff members had panicked at the Managua hospital that treated the patient, with some refusing to carry out routine patient care. The situation was dealt with by explaining the ways in which AIDS is transmitted and calling for more understanding and rational behavior on the part of health professionals.
Problems and possibilitiesNo one really knows what kind of profile AIDS will develop in Nicaragua. The health authorities at MINSA are hoping that the education and prevention campaign will be largely successful, but there are no illusions about the problems that a full-blown epidemic could create. Looking ahead to that possibility, MINSA plans this year to lobby for legal protection for AIDS patients.
As Dr. Alvarado says, "We hope to see some measures introduced that would protect the rights of AIDS victims. We've been very moved to see the situation in which AIDS patients throughout the world have found themselves.” Ironically, according to Dr. Alvarado, the US economic blockade against Nicaragua has had an unintended "benefit" for the country, in that it has limited the entrance of blood products contaminated with the HIV virus. "One particular problem we do have," she commented, "is that, due to the war, a great deal of blood is necessary, and therefore a great number of transfusions are done in the country.” She also pointed to something that could well pose a very real problem to Nicaragua in the coming months. “There is a particular problem in border areas, as there is in every country, and with all the refugees coming back, the thousands of repatriates who have spent years in Honduras could well be a significant risk group."
Many of the refugees who are returning have spent years in the areas in and around contra and US bases in Honduras, which is precisely where that country's AIDS cases are concentrated. Rita Arauz touched on yet another potentially potent source of the HIV virus. "I think that as we find out more about the intimate lives of people, we'll have a few surprises. For example, one issue—the tip of the iceberg, we could say—is the incidence of bisexuality in this country. Given this society’s sexual repression against homosexuality, many people live a kind of 'double life'—they form part of an ongoing heterosexual couple, yet they also engage in homosexual activity. I think all this will start to come out, just as the whole question of people who are part of two or three heterosexual couples has come out."
And finally, as Jeff Gates points out, "As internationalists, we need to understand that we constitute a real risk for the transmission of AIDS to the people of Nicaragua.” The Ministry of Health has called on the government to test all foreigners who visit Nicaragua (an estimated 8,000 a year), though they concede that the cost of the exam is prohibitive and simply not realistic, given Nicaragua's economic situation. In the past, foreign delegations were encouraged to donate blood to the Red Cross; few donations are now accepted from foreigners.
The fact that Nicaragua has to deal with AIDS may well create an opening for the gay community here. Rita Araúz says, "In Nicaragua, which is a revolutionary country, the opening—because we can't say there's total acceptance, but there is an opening—in terms of homosexuality is completely different from that which existed in earlier revolutions. We're not against the 'establishment,' we're not working against the government, but rather are working inside this process. The government has taken an open attitude towards AIDS. MINSA has been very careful to prevent a backlash against the homosexual community. The revolution could have either just isolated the homosexual community and created a reactionary group, or work with them, integrating them into the process. And what we've seen is that, once more, the revolution has demonstrated its capability and its intelligence."