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  Number 341 | Diciembre 2009
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Nicaragua

The Health System Nicaragua Needs Is Preventive Not Curative

This general practitioner who specializes in epidemiology and has both worked for the health ministry and in the NGO world reflects on different aspects of the country’s health system.

Leonel Argüello Yrigoyen

Nicaragua’s health system is made up of various sub-systems: the armed forces—army and police—sub-system; the public health sub-system under the Ministry of Health (MINSA), which is the biggest one and is responsible for managing health on the national level; the profit-making private health sub-system, including various hospitals and social security medical enterprises; and the non-profit private sub-system consisting of health centers managed by NGOs and churches and of medical brigades that come from abroad to provide medical services to the most needy population. MINSA is responsible for governing, regulating and coordinating all sub-systems, but they are currently operating like “islands” as MINSA is failing to build communication and coordination “bridges” among them. The Health Ministry is thus failing to exploit a great potential in a country where nobody can improve things alone.

The need for preventive
health care in Nicaragua

Health systems implement models that combine preventive and curative care in different proportions. The emphasis on one type or the other depends on political, economic, social and cultural factors. During the revolutionary eighties we had a model that prioritized prevention. But from the nineties to the present day, including the current government, the model has prioritized curative actions.

Prevention doesn’t have the same dimension in the developed world as in our countries. For example, the fact that sewage systems were installed in those countries’ cities means that many illnesses have been eliminated for some time now. Poliomyelitis was eliminated in various European countries without the need for a single vaccine, simply by installing sewage systems. In Nicaragua, 64% of the population still isn’t hooked up to a sewage system, so we have to have more energetic preventive actions, to act in a different way and keep on vaccinating against polio and many other illnesses.

During the revolutionary years, the model was essentially preventive and we provided health information to the population on a massive scale so people could participate in prevention actions. That’s not the case anymore. Health officials are very reticent to talk, to communicate with the media or with people so we neither see nor feel the effects of educational health campaigns, even when we’re up against a serious dengue epidemic. This is very serious in a country like Nicaragua, where prevention is fundamental. What do we do when we’re at a dangerous cliff-edge? Put up a sign to stop people falling into the abyss or put a hospital at the bottom to provide health care to those who survive the fall? Isn’t the sign the cheaper option? Isn’t a preventive health system more appropriate and cheaper for our country?

I’m a general practitioner and was lucky enough to do my social service in the eighties in the South Atlantic Autonomous Region (RAAS)—known then as South Zelaya—which is one of the toughest places in our country. As José Martí said, “Man grows when faced with difficulties.” And of course women as well. In that part of Nicaragua we grew and were able to do many things, more even than in Managua, which had many more resources. The adversities and difficulties we faced forced us to grow.

I had the opportunity back then to work with the Health Ministry for over ten years on hygiene campaigns, in everything having to do with preventing epidemics and coordinating grassroots health campaigns at the local, regional and national levels. And the organized population always achieved more than we expected. Their capacity to give always went beyond what we could suggest to them as technicians.

Education is fundamental

Ever since I was a medical student I’ve been convinced of the need for preventive medicine, of the fundamental importance of health education and how vital it is for the population to participate in fighting illnesses. It would have been impossible to do as many things as we did in the eighties without these three factors: stressing prevention, mass health education and popular participation. And doing those things drastically reduced infant mortality; controlled practically all immuno-preventable illnesses such as polio, diphtheria, whooping cough and measles; lowered diarrhea-related mortality; did education on preventive health; and established an internationally recognized primary health care model. Thanks to those experiences, I now consider myself a “health educator” and have been a volunteer in various health education and communication programs aimed at both the population and doctors.

Ongoing massive education is fundamental. Forty years ago Costa Rican television had persistent campaigns telling the population to “Say please,” and “Say thank you.” And now all Costa Ricans say thank you and please. Ongoing education is fundamental to achieving changes. In the eighties we initiated a voluntary education campaign—”The doctor in your home”—that lasted for 11 years on television’s Channel 4 and was very influential. We also tried, unsuccessfully as it turned out, to promote other series like “The lawyer in your home” and “The carpenter in your home.” Educating people allows us to take steps, even giant leaps, forward.

Health is everyone’s problem

Nicaragua isn’t going to advance in the area of health if we only want to work with one sector of the population, be it the Councils of Citizens’ Power, people from one political party or certain religious groups, or even people from the Nicaraguan Community Movement… Illnesses don’t have political preferences and exclusion is a deadly poison in the area of health. Health is everyone’s problem and you can only move forward with broad participation, because everything is interrelated. If there’s a dengue epidemic—which there currently is—what’s the point of my eliminating all the mosquito breeding places in my house if my neighbor doesn’t do the same? What’s the point of recommending daily walks if walking around my neighborhood exposes me to being attacked or even killed? The uncertainty of the current political situation even affects our mental health, and we know that when the mind is affected our defenses drop and we’re more prone to contract all kinds of illnesses.

Sharing information and
alerting the population

There are things we already know in Nicaragua because they happen every year. During the rainy season, the rain increases diarrhea, malaria, dengue, flu, pneumonia… And when the dry season brings dust, there are asthma, allergy and dermatological problems… Peasants know they have to prepare the earth when the rainy season approaches and those of us living in the cities know we have to repair our roofs and clean the drains. These are basic things, a matter of common sense. And it’s the same in public health: MINSA is the guiding force with valuable information and has to alert doctors, health workers and the general population early enough about what might happen so we can prepare correctly. If it doesn’t, it won’t achieve the participation of the whole population and we doctors will end up making mistaken diagnoses or giving the wrong treatment due to lack of information, which should be public and provided opportunely.

For example, the fact that a certain percentage of houses is infested with dengue-transmitting mosquitoes and the dengue 3 serotype, which displays another type of behavior, is circulating is enough information for us to realize there’s going to be an epidemic. And if that’s the case, then a series of actions have to be put in motion. In public health you have to act based on information, not go around looking for guilty parties or blaming one government or another. We have to work for the people and if we’re clear about that basic principle then we already have a common starting point, which we have to strengthen and exploit.

If information isn’t shared it leads to disinformation. Those messages that “everything is under control” are actually negative because they provoke the opposite of what they ought to be seeking, which is a watchful attitude and participation by each individual and family and by the whole of society. You have to tell people the truth if you want their collaboration. Saying everything is under control is interpreted by most people as absolute security, and as a result those who took preventive measures in our houses, eliminating puddles and stagnant water, start slacking off. And those who were unaware and didn’t do anything continue doing nothing.

In public health you also have to take into account our lackadaisical, shrug-off-the-consequences culture, according to which people wait for the nurse to come to their home to vaccinate their children rather than taking them to the health center. That kind of dependence has to be eliminated. It’s up to us fathers and mothers to fulfill our obligation to care for our own and our children’s health.

MINSA must also try to forge a better and more ongoing relationship with the media, which play a fundamental role in educating the population. During the revolutionary years we sometimes had problems with the official media—curiously we almost never had any with the opposition ones, at least in the area of health—but we always tried to rely on them. The critical information provided by the media serves as a warning to the population and also to MINSA. This happened recently with the information about a series of supposed cases of medical negligence, which damaged the medical profession, in come cases unfairly; but it was actually a positive alert because it got people talking about malpractice, discussing things we didn’t want to listen to or reflect on in such a conservative society as ours. Society will never be able to change its situation if it doesn’t accept its own reality, like an alcoholic in denial about his or her problem.

If you don’t talk about it you can’t resolve it. If we can’t accept it as a fault, we can’t change it. And in that sense, those of us who believe we have certain knowledge are obliged to be constructively critical. If governments, whose function is to work to help the citizenry improve their quality of life, don’t accept criticism, what are they good for?

Guaranteeing health
through information campaigns

Prevention is fundamental to avoiding illnesses. Let’s look at one example. During the war of the eighties, the main cause of amputation of legs and feet was landmines. Since the war finished, the main cause has been diabetes. How much does a patient with a diabetic foot cost us? Various hospital stays, cleaning the infected foot, antibiotics that are increasingly expensive because of developing resistance, amputation, obtaining prostheses—which aren’t easy to get—and the resulting limitation on work opportunities. Wouldn’t it be less costly to conduct information campaigns to ensure that diabetics manage their eating habits and medications better? For any illness, information is the tool that guarantees better health. You need information to put prevention into practice.

To organize massive preventive information campaigns, it’s also important to take grassroots culture into account. In the eighties, mothers were one of the determining factors in the death of their own children, “killing” them without meaning to. Traditional culture had taught them that if their children had diarrhea they were “dirty” and had to be purged.… But purging dehydrates, so it killed them. That custom, which we managed to change through mass education in the eighties, has recently returned to homes because culture is very persistent. Many of the children who died during the recent rotavirus epidemic did so as a result of that custom. To transform it, you have to keep up the educational message on a daily basis, never letting your guard down.

In Nicaragua our culture is still fundamentally oral, so we do what granny tells us to do… No matter how much the figures about the end of illiteracy are applauded, the fact is that we still don’t know how to read. Between 25% and 40% of the peasants in the rural areas of Jinotega where I work don’t know how to read a single letter. In such conditions, knowledge is transmitted verbally from generation to generation so erroneous or outdated beliefs about health persist and carry a lot of weight. They can only be overcome through ongoing and massive education.

Free health services,
but problems getting medicines

In all of the governments since the eighties, this one included, the population’s main problem was never geographical access to health services. The revolution distributed health units across the country, ensuring everyone access to a doctor or health worker, as well as to a health post or center or hospital. That access was maintained with little variation during the subsequent governments. But since the nineties the model has changed from a preventive to a curative one. The main problem in this model is access to free medication, because there are never enough resources to guarantee it. Right up to the present day, if a person spends US$25 a year on medicines, $21 comes out of his or her own pocket, with only $4 guaranteed by the public health system. That was the great problem in all of the previous governments, and still is under this one even though all health services are free. We have to celebrate the free nature of the health services, because it complies with the principles of social justice and with the Constitution. But access to all the medicines prescribed remains a problem.

The main difference between the current government and the previous ones lies in the increased number of consultations in the public system. That’s all to the good, as it means increased coverage; but more consultations don’t necessarily mean better health care. In fact, the opposite is true. If I have 50 patients in a morning, then I obviously can’t do much more than watch them file past. Some people tell us, “I wish the doctor would at least look at me, because no sooner have I arrived than he’s writing out the prescription.” Quality health care is an expression of respect for people, and that must be worked on, especially now that more consultations are being provided.

Following this government’s announcement that the public health system would be completely free, more people have been coming to the health centers and hospitals. But not only does quality decline the more people there are; it also implies a greater consumption of medicines. And as the medicines budget hasn’t increased, there’s more frustration. If any public policy is going to be real, it has to be accompanied by a budget; otherwise it’s just discourse, or a good intention at best; and at worst it’s politicking. A policy is only effective if it’s supported by resources, by funding, by a budget.

Although the government says its priorities are health and education, it has cut the health and education budgets in each of its budget reforms year after year. There’s no correspondence between the government’s speeches, its purported goals and the resources it dedicated to achieving them. Next year’s budget has zero spending earmarked for investment—hospital and health center maintenance; practically the whole budget goes for operating costs—salaries, fuel, stationery—rather than increasing the medications, promoting their rational use or including other culturally-acceptable complementary therapies.

I think that if the government really thought about making access to health in the public system totally free, it would have calculated enough of a budget to cover medicines and improve the quality of health care. What has historically been most costly for the population: getting a consultation at a health unit or buying medicines? It’s the same story with free education, because the most expensive thing in public education wasn’t paying the enrollment fee or monthly charge, which in schools free of corruption was actually used for school upkeep and cleaning and to complement teacher’s low salaries. The most expensive things are uniforms, books, shoes, transport… and none of that is free. Truly “free” education is still just a utopia and a discourse, just as it is in the health sector, where the government’s political intention is welcome, but has to be actually applied by benefiting the neediest people with sufficient resources.

Continuing social competition
in the health services

Studies of poverty divide the population into quintiles, or different strata. All studies indicate that those who use health units least often are in the quintile of people with the fewest resources and lowest schooling levels, while those with more resources and more education use them more. This situation hasn’t changed in Nicaragua with the current government. When people with high education levels notice symptoms of some illness in their kids, they immediately take them to a health unit, while those with little or no schooling don’t.

There’s always competition between those with more education and those with less. There should be greater numbers of high obstetric risk pregnancies in the hospitals, but in fact they’re full of women with normal pregnancies. Thus some “compete” with others for hospital space and specialists’ time, which should be dedicated to higher-risk pregnancies.

That social competition hasn’t changed under the current government, fundamentally because its public policies don’t have enough financial support. But in addition—and this is important—it’s also because there’s seemingly no real interest in convincing society as a whole about health, an issue it’s so easy to agree on and that served as a bridge to peace in the eighties in Central America, when the whole region was at war. This government doesn’t accept the feedback or collaboration of sectors outside the government; active forces that have been working in the health area in Nicaragua for the last 29 years or more are being excluded.

We started the mass production of doctors in the eighties, and the same thing is happening now, but this time on the private level. A massive scale always reduces quality, unless we have quality control programs, which Nicaragua has almost never had. During the revolution we turned out many new doctors from poor social classes who lived in houses with earth floors, but who once trained never returned to their places of origin or went to work in the toughest areas. The same could happen again with the government’s current policy, which has doubled the number of resident specialists from 150 to 300, but based more on the students’ political sympathies than their quality. In addition, without the technical teaching foundations to bear the burden of so many new doctors, the quality of training will almost certainly drop.

MINSA is still strong, despite everything

There’s still time to alter this course if we make significant changes, recognizing all the limitations I’m pointing out and accepting that patients’ interests have to come first, because at the end of the day that’s the raison d’être of medicine and health systems. We have to remember that quality depends on the training and updating of human resources, the abilities and skills they acquire. Investing in future health personnel must be the main government investment aimed at improving quality. And that requires ongoing monitoring and evaluation. Prioritizing the painting of hospitals or providing them with new equipment and technologies without training those who will use them, as happened during previous governments, has had a great cost.

This government’s placing of party members in important posts, including public health, just because they are supposedly loyal, has also had a great cost. Social consciousness depends on the education we receive and acquire, not our class extraction. There are rich people with social consciousness and poor people without any. We’ve already seen that in Nicaragua, where a revolution has been betrayed by some of its leaders, who ended up living and acting like the very people they criticized and fought against.

But despite it all, the Health Ministry is still one of the most solid institutions in the country, perhaps because we made it so strong in the eighties but above all because a lot of people working there have a social conscience. It’s the ministry that has been changed the least since the eighties. Some governments have improved certain things and neglected others in MINSA, but it has suffered the fewest radical transformations. It is also one of the country’s most institutionalized institutions, and would continue functioning even if its central level was eliminated. It’s similar to the education ministry in that regard, because they are the only two that have territorial representation right across Nicaragua. Other ministries would cease to function if you lopped off their head.

The role of international cooperation…

International cooperation has played an important role in improving the health of Nicaraguans, but it has drastically cut its budget contribution for several reasons. In addition to the main factor—the cooperating countries’ rejection of the electoral fraud in the November 2008 municipal elections—the attitudes displayed by MINSA authorities have also influenced this decision. They have been unable to build healthy relations with many foundations that want to help Nicaragua and have traditionally provided the country health equipment and other kinds of collaboration but now find themselves blocked and don’t understand this unwillingness to benefit the population. For example, patients here have been deprived of cooperation providing access to pacemakers—which ensure that the heart functions at the required rate—purely because of obscene and anti-ethical political intentions that make absolutely no sense.

International cooperation has also been influenced by seeing the Health Ministry close itself off to NGOs and other civil society bodies that have been working in health effectively for years and have continued working with the preventive health model of the eighties in different ways, helping improve it.

...and of medical brigades

Foreign medical brigades have been coming to Nicaragua since before the eighties, and there are also national brigades of ophthalmologists, Sandinista doctors, the Rotary club, different churches… All do excellent work, but they only resolve immediate, isolated problems. In the eighties, we created health brigades to extend health coverage to places where there was still no access. In military terms—and public health has its origins in military strategies—the health brigades were the front line; once they had taken possession of a territory a health center could be established. Public health has its origins in military strategies.

Medical brigades can have both a technical and an ideological meaning—building social awareness—but for the latter to be true they have to be voluntary. It’s an inadequate use of this initiative to send specialists out in brigades to resolve problems that could be resolved by general practitioners, not because the population doesn’t deserve them, but because it isn’t getting the best out of specialists. Wouldn’t it be much more effective to reduce the waiting lists or voluntarily increase working hours so that those people who want to give more of their contractual time in both hospitals and health units can do so and with greater efficacy?

Brigades are a flash in the pan, joyful while they last with long queues for consultations, but when they leave, the people return to their previous situation. That’s why brigades always have to be viewed critically, assessing their cost, efficiency and efficacy and evaluating what they leave behind that the population can sustain.

During the revolution, we did grassroots health campaigns with the aim of rapidly increasing coverage until we could establish systematic vaccinations for children under a year old. When I proposed analyzing the financial cost involved—there was still no such thing as health economics at the time—we weren’t allowed to do so, under the argument that you couldn’t put a price on health. But that’s not true. Health has costs that someone must always pay, and they’re high ones. It’s very important to know exactly what subsidy is being provided in order to assess the sustainability of any such initiative. The same questions are still relevant and in fact even more pressing today: in a country like Nicaragua, how much do the medical brigades organized by the government or by civil society cost? How useful are they? And how could we do things better?

The government’s mysterious
new health care model

The government has announced that it’s now implementing a new community health care model, but I’ve yet to find anyone who can explain to me what it consists of. I ask the health unit directors and they don’t know what to tell me. I ask the nurses and they tell me that it’s the same model as under the previous government, except that now the doctors are going to make home visits. I feel that so far it’s more about talking about a change of model than actually establishing one.

Some people have told me that the new model will be based on Cuba’s model, but there are huge differences between the two countries. Cuba has a massively educated population with an educational and cultural level only found among Nicaragua’s middle and upper classes. There are Cuban teachers with doctorates, while here we have teachers who didn’t even finish primary school. There’s also a greater culture of hygiene in Cuba. You notice it if you get on a Cuban bus, or are in the streets or go into the houses. There used to be a doctor in Cuba for every block, although that’s no longer the case because they’ve sent thousands to Venezuela and other countries, but despite everything the whole population is extremely familiar with the health personnel. In short, Cuba’s reality is totally different from ours. In fact, the Cuban model wasn’t even used in Nicaragua during the revolutionary years, although we did take elements from it and other country’s models that we considered most useful. And obviously, we can never be grateful enough for the enormous solidarity shown to our people by the Cuban people and government, in dimensions that have still to be recognized.

How is the new model being implemented?

In any change of model, particularly a change of the health model, the first thing that has to be done is to woo and win over the people. You can’t establish a model if the very people introducing it aren’t clear about what they’re going to do. But even supposing they support the change, the first thing is to explain the model to the health workers. And that hasn’t been done. Not even MINSA’s human resources are clear about the new model, and they haven’t been trained for what they’re going to do in it. The NGOs working in health aren’t clear about what is wanted either. Then, after the sensitizing and wooing, the model can only be implemented with financial support, investments in human resources and in equipment and infrastructure.

So far all that’s been done to implement this new model is to distribute the geographical areas of attention among the doctors, and that’s been done without considering whether the doctor appointed for such and such an area might have developed skills in attending children and will now have to treat adults, pregnant women and the elderly. A change of model must take into account not only the extent to which the model is embraced by the health workers, but also their training and the development of new skills for the new challenges.

Food security: The lessons
Zero Hunger could have learned

Food security is fundamental to a population’s health. Good hygiene and nutrition would ensure good health in Nicaragua, and it doesn’t cost as much. Malnutrition levels are still high in our country, compounded by the fact that we Nicaraguans don’t know how to eat, because we consume tasty rather than healthy things. More Coca Cola than milk is drunk in Nicaragua, even though we’re a cattle raising country; and people in the countryside sell their eggs and bananas to buy Gerber-style processed baby food for their children, or worse yet to buy junk food, which is much less nutritious. We also have a very powerful “broth” culture, believing that the water used for cooking beans, chicken or iguana contains the most nutrition. So that’s what the children are given, while the beans, chicken and iguana itself are eaten by the adults. But that colored water doesn’t offer any nourishment to speak of. These are cultural problems, but we don’t see any government prevention campaigns on good eating and nutrition habits.

The government’s “Zero Hunger” program has tried to improve food security, but after the government announced it as a program to pull together all of the efforts of this nature made by civil society over the last 17 years, Zero Hunger’s big weakness has been that they didn’t actually do that and thus failed to incorporate any lessons learned by any other group. Believing they could go it alone has been a serious mistake. You have to add, not subtract, and Zero Hunger hasn’t had the expected impact precisely because it failed to do that, among other reasons because party interests don’t always coincide with people’s needs. It would have had a real impact if the government had brought together all the NGOs that have worked on similar programs and accumulated knowledge to jointly analyze the lessons and main limitations and share their educational materials.

After 25 years working in programs to get people out of poverty, one learns, for example, that you can’t give a family an animal that eats more than the family does, which is what has happened in Zero Hunger because they’re giving out pigs, which eat more than a rural family. Getting out of poverty is a gradual, progressive process. It implies progressing through stages and requires education to learn to eat healthily. NGOs have distributed 10,000 improved hens in rural zones in recent years, as they’ve turned out to be the most effective animals due to the nutritional elements in their eggs, which quickly and efficiently provide protein. We achieved this distribution using a revolving credit system in which each woman pays forward in kind, i.e. with hens, and has 10 eggs a day to improve her income and feed her family. The following is the order of preference for distributing animals, from most appropriate to least appropriate: improved chickens, rabbits, Pelibuey sheep, tilapia fish, pigs and cows. And this distribution should always include prior training and be accompanied by environment-friendly agricultural technicians who know about techniques such as soil and water conservation, compost, worm humus and crop rotation.

Further reducing infant and maternal mortality

Two indicators are always taken into account when measuring a country’s development indices: infant and maternal mortality. Both rates are dropping throughout the world, and Nicaragua is no exception. But we could make much greater progress without much cost. If, for example, we improve the quality of water, it would improve health in general and there would be fewer diarrheic diseases and therefore less infant mortality. And if we simply washed our hands, there’d be fewer parasitic diseases and less infant mortality.

There are simple and cheap ways to improve water quality, like the solar disinfection technique. All you have to do is thoroughly wash out big plastic bottles, the kind used for Coca Cola or other soft drinks, fill them with clear water or water that has been filtered through a cloth and place them on the roof for four to six hours so the sun’s ultraviolet rays can purify it. If this process, which costs just pennies and produces healthy water with a better taste than either chlorinated or boiled water, were generalized through ongoing education campaigns, it would have a decisive impact on the population’s health as well as making good use of the plastic bottles for six months. The bottles could then even be recycled by some small-scale business, thus making better use of a contaminating plastic material that can take up to 500 years to break down—or often gets burned with other garbage, releasing toxic dioxins.

This government has made important efforts to reduce maternal mortality, but could do much more. It would involve MINSA opening up to the whole population and having everyone working in the same direction, which isn’t exactly this government’s style. I don’t believe anyone should go around applauding because fewer women are dying today than a year or two ago. Not a single pregnant woman should be dying, and even one death should concern us because maternal mortality as the result of pregnancy is one hundred percent preventable.

Furthermore, how much has this government truly reduced maternal mortality? It’s hard to get access to reliable data. We know this government hides data that ought to be public, that there are public hospitals ordered to announce official data of zero maternal mortality and to say they have medicines, when neither fact is true. Given such a lack of transparency, the data they do give lose their value and reliability. It’s worth pointing out that during the eighties MINSA never hid a single piece of information, no matter how negative it was.

There are still cases of maternal mortality because sometimes women who give birth in hospital are two or three to a single bed, get discharged immediately and aren’t given any education. They sometimes aren’t even told basic things, such as that bleeding after the birth or having a bad-smelling vaginal secretion isn’t normal and they must immediately return to the health unit. We come across many women in rural zones whose husband has told them it’ll go away, so they don’t seek help, but it doesn’t and they grow weaker and are already in a state of shock by the time they reach the hospital. In Jinotega we’ve found cases of women who died because their husbands didn’t give them permission to return to the health center. This could be resolved by strengthening the “maternal centers,” which were invented so women from remote rural zones could go there for a short while before going on to the hospital for the delivery then could stay in these centers for at least 24 hours afterward to receive education about the danger signs and how to raise their children, stressing exclusive breastfeeding.

It isn’t a problem of resources; it’s about the government and all organizations that work in health joining forces. This and all other health problems are best resolved by everyone talking to each other and sharing with others who have had other experiences and worked with or studied other initiatives.

It’s the government’s responsibility to combine efforts so we don’t view maternal deaths as something natural, something that’s always going to happen; so we’ll feel the death of each woman as a national shame that we could have prevented.

The problems caused by
criminalizing therapeutic abortion

Another problem in Nicaragua related to maternal mortality is the criminalizing of therapeutic abortion. It has been demonstrated in all countries that doing so doesn’t reduce the number of women who have abortions by choice. There are three kinds of abortion: spontaneous abortion, or miscarriage, which is decided by nature; therapeutic abortion, which results in the woman’s death if not decided on and performed by the doctor; and abortion by choice, which is the woman’s decision. These three kinds of abortion are put in the same sack in Nicaragua, to penalize them all. Spontaneous abortion isn’t avoidable and therapeutic abortion isn’t preventable, while chosen abortion can be prevented, because its origin is an unwanted pregnancy due to rape or to some economic, psychological or other reason. If we could autopsy the young women who commit suicide in Nicaragua to learn why they did it, we would surely discover that most had an unwanted pregnancy or didn’t know how to or couldn’t tell their families that they were pregnant.

There has been a great contradiction in the public health system following the criminalization of therapeutic abortion. On the one hand, the Health Ministry’s obstetric guidelines tell doctors they can interrupt any high-risk pregnancy that puts the woman’s life at risk. But over and above these guidelines is the country’s Penal Code, which says they are committing a crime if they perform a therapeutic abortion. And then over and above the Penal Code, and any other law for that matter, is the Constitution, which can be interpreted as ordering doctors to save the woman’s life. So doctors are faced with a great dilemma: if they perform a therapeutic abortion they could be sent to jail, even while the general health law orders them to care for the woman’s health. In this sea of contradictions, what’s happening in practice is that therapeutic abortions are being performed in some places, but discreetly, letting more time go by than is appropriate and putting the women’s lives at greater risk.

So we’re seeing cases of women arriving at hospital with vaginal bleeding and nobody wants to treat them, because health professionals are afraid some accusation will be made and they’ll be stripped of their right to exercise their profession... What’s happening more generally is that the health care provided to patients is delayed as doctors seek to avoid any danger, knowing they could face accusations. So doctors’ human rights are being violated, on top of the women whose right to life is being violated by leaving them only the option of death. Another thing happening is that patients turn up very late at the hospital out of fear, as many of them link abortion with prison.

There’s no scientific reason to criminalize therapeutic abortion. In Nicaragua, the reasons were only political during an electoral period and to sit well with the Catholic Church hierarchy. As a result, those suffering most from this law are poor women. In addition, this law is essentially discriminatory because it only affects women, despite the recognition that women are the backbone of their families and our society. For all of these reasons, it is a profoundly unjust law that violates an important number of human rights recognized in the Constitution.

There are cases in which therapeutic abortion is the only way to save a woman’s life. No matter how much medicine has advanced, it still hasn’t managed to avoid this in serious cases. Therapeutic abortion is penalized in only five countries in the world because penalization is scientifically and medically unsound. Only one percent of all abortions performed in Nicaragua are therapeutic. So what’s the sense of penalizing them if we already know it will neither eliminate nor reduce elective abortion? It simply makes them more expensive, more clandestine and less safe.

Reducing the number of abortions should involve avoiding unwanted pregnancies. It has been universally demonstrated that an undesired pregnancy can be prevented in three ways.

The first is sexual education, which allows someone to be prepared and to say no. This is quite contrary to what some think, which is that it will lead to more promiscuity and more sexual relations. All studies demonstrate that more sexual education leads to greater sexual responsibility and delayed initiation of sexual relations.

The second way is access to birth control methods. This is an area in which we have already advanced a lot in Nicaragua, although we can’t let our guard down.

And the third is adolescent-friendly services, because there are intergenerational problems in talking to young people about sexual issues. If we took up all three ways in Nicaragua we’d see a notable reduction in elective abortions.

Sexual abuse and machismo

At this point we also need to talk about a public health problem that we don’t address, don’t even accept and definitely don’t want to talk about: sexual abuse. There are many obstacles to understanding sexual abuse as a public health problem in Nicaragua. The first is a very deep-rooted machismo, and the second the fact that the laws don’t work and people who press charges don’t receive any justice. All rapists should be in prison, but most are walking around free, which is logical when you consider that many people with power have committed that crime and are free because nobody is going to dish out punishment to himself. The impunity of the powerful stops justice from functioning and stops this problem from being seriously addressed by the institutions and society as whole.

In a program with an international NGO in Ciudad Sandino working with 10- to 14-year-old boys and girls, we’ve confirmed just how deeply-rooted machismo already is in that age bracket. The 10-year-old boys say with no embarrassment at all that you have to hit women, that women are there to have children and that you can touch them whenever you want. They already have their role as machos well defined at that age. And there are girls of that same age who say the only thing they want is to get pregnant so they can leave home, because they get hit at home, are forced to do chores, or their brothers or stepfather touch them up and they don’t like it.

Prevention is also needed in this area and we have to start working at these ages, during pre-adolescence, to deconstruct in time the learned machismo that generates so much violence. Just as illnesses are biologically transmitted, machismo is a culturally transmitted illness and we have to cut off the transmitters in order to form different generations. We have to work on this from a very early age, and when we do work with boys and girls we discover that their mothers went through the same thing: they were raped, hit, abused… We also discover that all of this machista violence occurs in both urban and rural areas, that men feel they have the right to behave that way and that when they get away with it they boast and urge others to imitate them.

Even in NGOs that work in the health area there’s not enough awareness of sexual abuse as a public health problem, one that crosses all social classes, political parties, ideologies and religions. We don’t talk about that. We don’t talk about the sexual abuse committed by Catholic priests or Evangelical pastors. And it has to be talked about. We have a surprising tolerance for sexual abuse in Nicaragua. We’re so intolerant in our political culture, yet so tolerant of this disaster. Because the fact is that sexual abuse destroys girls’ lives, and if on top of it all they get pregnant then things get even worse, as they have to leave school, stop studying and risk their health, compromising their development and future. Early and rape-induced pregnancies have personal, emotional, economic and social consequences, generating a chain of problems that affect all of us all and the country as well.

Sexual abuse is a taboo subject in Nicaragua and all taboos start to be confronted only by talking about them. We also need to generate a culture of prevention in this area, to educate and overcome the short-term culture.

The “demographic dividend”
is a great opportunity

In the next 30 years, Nicaragua will have the biggest young, working-age population in its history, thus presenting us with an opportunity known as the “demographic dividend.” Exploiting this opportunity involves investing in quality education. But if we miss the opportunity, that large population will age and become a heavy burden on a smaller young population unable to respond to the country’s underdevelopment due to its lack of education, among other reasons.

We can’t waste this opportunity. Intelligence can be imported, bought or produced. Mexico imported intelligence in the form of exiled professionals who helped change the country through the universities, while the United States buys brains from all over the world because it has the resources to attract them. But we don’t have those resources, so we have to produce our own professionals who will transform our country. Why not give university scholarships to the best pupil from each of the country’s 154 municipalities? This prize wouldn’t go to the pupil with the most economic resources, but rather the one who puts in the most effort. Then in a few years we’d have 154 top quality professionals to help resolve our problems.

In the Somoza era we learned to join together, combine forces to defeat the dictatorship. Then came the revolution, where we joined forces in the area of health, which helped us achieve substantial changes, despite limited financial resources. But in other areas people didn’t continue joining forces, but rather learned to keep subtracting, which was to a great extent another expression of our culture of intolerance.

In a country like Nicaragua we have to start combining forces again. We have to learn to agree on what unites us rather than insist on our differences. Doing things the other way round is characteristic of Nicaraguan culture, but our health demands that we overcome this. To achieve this we can count on our people’s infinite capacity for participation. Let’s not miss our chance again. Our generation has to leave a better country to the new generations of Nicaraguans. Until we do this we won’t have fulfilled our duty as citizens who aspire to a more just, equitable, democratic… and healthier society.

Dr. Leonel Argüello Yrigoyen worked at MINSA during the eighties, then as director of a national and international NGO for 19 years. He is currently president of the Nicaraguan General Medicine Society.

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