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Central American University - UCA  
  Number 467 | Junio 2020
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Nicaragua

“Our health system responds to political orders, not to the public”

This epidemiologist brings his long experience in public service to bear in comparing the public health system of the 1980s with now and analyzing how it has handled COVID-19… as of May 15.

Leonel Argüello Yrigoyen

After 44 years working in this profession, I am now, for the first time in my life, seeing Nicaraguans asking—crying out for—us to guide them about what preventive measures they should take to avoid infection by COVID-19. It’s never been like this before. Ordinarily, the public has gone to the health system for treatment, not prevention. They ask for more caring attention, one that actually sees them as people when they visit the doctor, doesn’t leave them waiting so long, doesn’t keep delaying scheduled operations, has enough medicines on hand … These are the usual requests. They show more appreciation for a doctor who operates on them than one who prevents a disease. Furthermore, we are no longer even trained in health prevention and this is precisely what we must change in this country. Today, when the pandemic has forced people to take an interest in knowing how to avoid infection from this virus, they find the health system unresponsive to their needs because it wasn’t prepared for prevention. We’re seeing that this lack of foresight will result in more serious consequences from the pandemic.

The Ministry of Health: preventive
care in the 1980s, curative now


In the 1980s, the revolutionary decade, Nicaragua’s Ministry of Health placed great emphasis on preventive health care, perhaps because those of us who ran the ministry felt we were building not only for the present but also for the future. Modern medicine is preventive: it tries to anticipate what will happen to people in order to prevent it. In the 1980s we didn’t have as much knowledge as we do now, but we were very aware of the importance of prevention and we had voluntary public involvement in the health campaigns. Even those who didn’t believe in the revolution participated in those campaigns. Health motivated unity, and we united in preventive activities: vaccination campaigns, anti-malaria campaigns, clean-up campaigns…

In those years there was a close link between prevention and involvement. It was really broad-based, and without any kind of political pressure. My job during the revolution was to run those health campaigns and we had more than 20,000 health brigade workers throughout the country under my supervision. We saw that people have immense capacity and gave more than we asked of them. Because they exceeded our expectations, we decentralized the guidelines and the campaigns so they could respond better to the reality of each area. We gave the people autonomy because sometimes people have more capacity than those leading them.

People’s involvement in their own health care began to decrease from the 1990s on. Preventive care was relegated and curative care imposed. Instead of people going to the health units for vaccinations, for example, health workers went to people’s homes. The disadvantage of this was that the population became passive and waited for the health workers to come to vaccinate them. Parents no longer knew if their children were at risk of contracting the given disease because they were no longer keeping track of whether they had gotten the right number of doses. Waiting for vaccinations wasn’t educational because although the Health Ministry is responsible for vaccinating my children, I should be responsible as a parent and a citizen to ensure that they are vaccinated.

People’s role in health care
in the 1980s and today


People’s practice in the 1980s of taking care of themselves and their family, and even participating in caring for their community began to be lost starting in the 1990s, and people were demobilized. The Health Ministry (MINSA) became an institution that provided basically welfare-focused curative services. It has been so under different governments and even more so under the current one. The voluntary health brigade movement has lost its provenance in volunteering, becoming instead partisan and separated from the original social motivation, which was to support others without expecting anything in return and without excluding anyone.

That original community health model wasn’t linked to the ruling political party in the 1980s, whereas the one the government talks so much about now as a solution to the pandemic is. As far as I was aware, it wasn’t exclusionary, although exclusion may have existed in some places. Nor did participation give anyone privileges; what mattered was serving. This model became corrupted over time and volunteering no longer exists. Mobilizing capacity in the communities doesn’t exist either, because now you get paid in cash or in kind, as those same health brigades are sent out to give people a mattress, a stove, a bag of food… Of course, giving these things feels good, but previously what we gave was education. Last year, there was no community mobilization about dengue, even though it was recognized as an epidemic and people were known to be dying.

What does it mean
to administer health?


A good health system must be managed consistently. At the head is the system’s health ministry, which by law in Nicaragua’s case controls all health subsystems: those of the Police and Army, the companies administering Social Security, and the private hospitals and clinics. Today, Nicaragua’s whole system is overwhelmed and on the verge of collapse and MINSA is not acting as a national health administrator.

Administering health means that if various viruses are circulating in a country, the health ministry knows about it from its laboratories and must inform us doctors which ones they are so we know which protocol to use. It’s the same with bacteria: the ministry’s job is to inform us which ones are circulating, what symptoms they present and which antibiotics they are sensitive or resistant to. It’s also the responsibility of the health administration to collect information from the subsystems so as to form a detailed picture of the health reality throughout the country. To help do this, it may, for example, have randomly selected “sentinel schools,” which report on how many children have stopped attending, enabling it to detect in time if a flu or diarrhea is already in the country and warn all the other schools and the country as a whole.

In a pandemic situation, a health ministry isn’t just the institution in charge of health; it almost becomes responsible for governing, for the State as a whole. It must coordinate all the institutions, putting them to work to deal with the pandemic. This hasn’t been done here. All we’ve seen are speeches telling the population not to be alarmed, assuring them the hospitals were prepared and that we have the best health system in Central America and even the world.

The scientists warned about it,
and the politicians denied it


Any epidemic puts a health system’s preventive mechanisms to the test and, at the same time, shows up the ability of its available information systems. So, how is it possible that I, an ordinary epidemiologist not working in a research institute with all the latest information, knew since December that the coronavirus was going to come to Nicaragua sooner or later? And when I saw how fast it was traveling to other countries, I was 100% sure it would arrive here soon. Scientists everywhere knew the virus was coming with considerable force and here, as everywhere else, it was the politicians who tried to deny and hide reality. In several countries they covered it up as best they could—some partially, others completely—and now we citizens are paying for this irresponsibility.

There are inconceivable numbers of deaths in the United States, the most powerful country in the world. It’s thus inconceivable that they would want to risk more contagion for economic reasons. Many infections and deaths throughout the world could have been avoided, because we can largely control this virus by washing our hands frequently with soap and water, keeping a distance of five feet between people, staying home and wearing a face mask or a plastic face shield when we go out.

We warned about it but
didn’t prepare people


We medical professionals have known about this virus’ obvious characteristics—its capacity for infection and speed of contagion—since December 2019, and we warned about it, but we should have started a preventive campaign back in January based on what was already happening in other countries and knowing that controlling the virus and preventing contagion requires avoiding close contact between people. Preventive measures and a campaign to publicize the transmission routes should have been started from that time forward. However, none of that was done and, in my view, it still isn’t being done.

By mid-May there was some kind of timid campaign in the government media, but I never see their own reporters or interviewers practicing social distancing, which is an indispensable preventive measure. We learn by example, and examples send more convincing messages than words. We’re also still seeing public events being promoted where people aren’t keeping the necessary distances but are crowded together and spreading contagion.

Even now, with the hospitals already full and dozens of deaths not officially recognized in the admittedly rising official figures, there is still no serious, massive prevention campaign. At no time since March 18, the date the pandemic officially arrived in the country and the first death was acknowledged, have we seen a coherent approach to the pandemic led by the government health system.

What we do and don’t
know about COVID-19


This disease is caused by a new virus we are gradually getting to understand. It not only spreads very rapidly but is very potent in damaging all the body’s organs. The hepatitis virus only attacks the liver; the meningitis virus attacks the layers around the brain and no other organ; the rotavirus attacks the intestinal system; and the influenza virus attacks the respiratory system, but this coronavirus first affects the lungs and then inflames and damages all the body’s organs. It then affects blood coagulation and can cause blood clots that obstruct arteries, which can lead to a heart attack or stroke. It finally attacks the immune system itself, causing it to turn against normal body cells, which it identifies as enemies and kills.

Prior to December 2019, world health workers had never faced a virus like this one, which first appeared in China and rapidly turned into a global pandemic. In addition, we don’t know how this virus will mutate or if, when the vaccine is ready, it will have already mutated, rendering the vaccine useless. We do know that several strains of the coronavirus are already in circulation, but there isn’t enough research. Viruses generally mutate as they pass to more and more people; they are always changing. The goal of viruses, just like that of humans, is to survive, and to do that they adapt. If they enter bodies with good resistance, they learn from this experience and when they enter other bodies, they already know how to attack it more effectively.

What do we know about
COVID-19 immunity?


Flu viruses come from different families. There are nine viruses in the coronavirus family that cause flu. So far only three of these have caused serious diseases: SARS, MERS and now SARS-COV-2, which causes COVID-19. It is the most serious of those known so far, and there’s still a lot we don’t know about it.

All coronaviruses cause flu, respiratory diseases, but not as serious as the one we face today. Most of us have already had flu caused by different coronaviruses and we know that, once the flu has passed, we aren’t left permanently immune because every year we can get the flu again. We know COVID-19 causes immunity in people that has lasted for at least 140 days since the pandemic began, but we don’t know if it will be permanent or, if temporary, how long it will last. This fact alone invalidates adopting the “herd immunity” strategy, which hasn’t worked in Sweden. It has been a perfect failure, which we knew it would be from the get-go.

Herd immunity isn’t a viable
strategy for this pandemic


Seeing how contagion has actually been promoted in Nicaragua through the organizing of numerous large public events since March, the beginning of all this here, some suspected the government was opting for “herd immunity.” Years ago, before there were measles vaccines, if we children caught it, siblings and cousins were put together so they all got it at the same time and all became immunized. It was a form of family herd immunity. When vaccines came along—one of the best practices in public health—we were vaccinated to get immunity and that family practice was forgotten. Putting together in an organized way someone who has the active disease with people who aren’t immune to ensure collective immunity is known as a herd immunity strategy. Great Britain’s prime minister thought of promoting it with this coronavirus when there were only 56 deaths and they were expecting 22,000, but he contracted COVID-19 himself and soon abandoned the idea.

Herd immunity makes sense when it’s certain that permanent immunity will be achieved, which isn’t yet certain in the case of this coronavirus. It’s also extremely complex to apply this model properly when dealing with a pandemic. In our case, if an outbreak begins in the municipality of Mateare, for example, it would have to be totally closed off so the whole local population could catch it. It would also be necessary to ensure that there was a good hospital in the area to attend to the number of people affected, which could be large. Later, the same must be done in another municipality, and then in another, and so on…

Epidemics, however, don’t pass from one municipality to another in such an orderly manner; they behave according to the internal migratory movements and dynamics of a country, developing more rapidly once they enter places with greater population density. Nicaragua has about 50 inhabitants per square kilometer. The municipality with the densest population is Ciudad Sandino, with 3,000 inhabitants per square kilometer, followed by Masaya with 1,000, then Estelí and then Managua.

What has the government
done about the pandemic?


The government promoted contagion-inducing mass activities, assuring the public that the virus was “imported” and there were only a few cases, even when it was already in the community contagion phase. An FSLN legislative representative said the health system’s “magnitude and capacity” was such that it wouldn’t collapse because “we have 11,732 beds, 562 beds in intensive care, 449 respirators and 954 vital signs monitors.” I don’t know if the figures he quoted are correct but, despite being a health professional himself, he showed by talking this way that he either didn’t know anything about this pandemic or was intentionally creating a false sense of security, as others have also done.

No country in the world, even one with the best hospital system, has been able to withstand the speed with which this virus spreads. Any child from a developed country could have explained to this legislator how this virus is averted. In any case, it’s criminally irresponsible to encourage people to cross the road when the lights are red just because there are hundreds of ambulances ready to pick up the injured…

In none of the government’s behavior is there any sign of recognizing the main, already proven preventive measure: social distancing. Classes in public schools haven’t been suspended; there’s no restriction to people’s movements on the streets; no kind of quarantine or any economic measure to make it easier for the poorest people to stay home. No measure of any kind has been taken to prevent contagion. Washing down the markets every week with chlorine is an excellent idea, which should be done daily, but this doesn’t control COVID-19. You can wash down the whole of Managua with chlorine and it won’t decrease the disease. The only way to control it is social distancing.

Is the government’s behavior logical?


Many ask me, and we medical professionals ourselves wonder, about the logic behind the government’s treatment of the pandemic. There is no logic at all. Calling for crowds is tremendously reckless. It puts the whole country at risk because the more sick people there are the more hospital complications there will be. It’s directly proportional. There’s no herd immunity strategy, because that strategy requires accurate and continuous statistical information as well as considerable organization, and there’s been none of that in Nicaragua. I don’t think there’s been any plan from the very start; the government’s unwillingness to admit the disease exists and is serious or needs prevention tells me there’s no plan to deal with it.

Denying a reality that’s happening all over the world, in our neighboring countries and also right here is irrational. Worse yet, the authorities’ denial of reality means there are people in Nicaragua who aren’t aware of the disease and trustingly go to the festivals and sports and political activities organized by the government. They think—some from political fanaticism, many from unawareness—that the virus isn’t here or won’t do them any harm or Nicaragua won’t be affected the same as other countries. They believe this even though the whole world knows the virus is real and does tremendous damage. COVID-19 doesn’t discriminate, it affects everyone.

No serious preventive measures have been taken here so far. This is particularly serious since there is so much poverty, and most people have other ailments that aggravate the damage the coronavirus can cause. Most poor people are obese, especially women. Obesity not only makes us prone to 13 different types of cancer, high blood pressure, joint problems and diabetes, which 13% of Nicaraguans suffer from, but also aggravates the effects of COVID-19.

Nicaragua has no public policies promoting healthy lifestyles, which do prevent diseases. When have governments ever had public policies that facilitate poor people’s access to healthier food? They eat greasy and extremely sweet things. Why isn’t eating fish promoted in our country? Post-earthquake Managua is no longer a people-friendly city; it is being modernized for vehicles, not for citizens wanting to exercise or ride bicycles.

No vaccines or proven cures yet


As I already mentioned, the Nicaraguan health system has prioritized cures, not prevention since the 1990s, but no vaccine or scientifically proven cure has been found for the coronavirus yet. No medication has been proved effective in treating the disease. Random medical experiences that one medication works on some patients and another on others are all we have, but this doesn’t mean any one of them can be given to everyone. So far, what has been done in other countries is to use a medication on one group and not on another control group so as to later evaluate the results, but there are variables within the medicated group that can confuse the response and alter the conclusions, for example if someone has high blood pressure, is a smoker, has some other disease or previously took another medication…

If a medication works once or several times, that doesn’t accredit it as valid for use on all patients, which is why medication evaluations entail up to 300 studies that analyze different research and experiences. What is being done all over the world is called “compassionate” treatment, trying to see which existing medicine works better than others.

Curative care during the pandemic


In Nicaragua, curative care hasn’t done so well during the pandemic. I’ve spoken to patients who went to the hospital, were taken to the emergency ward, examined and given various tests, then sent home after being told they had pneumonia or some other diagnosis. They weren’t given any further explanation or told which preventive measures they and their families should take.

In the cases I know about they were given an antibiotic (azithromycin), an antimalarial (chloroquine) and an antiparasitic to take at home. But combining azithromycin with chloroquine can affect the heart so an electrocardiogram is required prior to prescribing it, and heart monitoring should be done every two or three days. These obviously aren’t medications to send people home with to take on their own, but this is what is being done. It’s bad medical practice, knowing that we Nicaraguans are accustomed to self-medicating and readily take any pill. We haven’t been taught that any medication, just like any natural medicine, has benefits but can also have harmful side effects, which is why a doctor should assess both benefits and risks. This isn’t a disease for which we can prescribe proven medication. More important is to give advice on all the preventive measures the family should take and what they have to do when someone has the symptoms, or if they get worse.

Those going to the hospital emergency are also often being sent home the same day, after being told the result of the COVID test they were given was “indeterminate.” But “indeterminate” isn’t part of any scientific criteria. It isn’t a valid result. There are only two results: positive or negative. If it comes out “indeterminate,” the test must be done again because there has to have been an error in taking the sample, preserving it or processing it in the laboratory.

Both medical and
political malpractice


The specific cases I’ve known up close show medical malpractice in addition to everything the health system didn’t do preventively. This malpractice and other errors occur because MINSA hasn’t discussed with its doctors how to treat those infected. There’s been no official public regulation or protocol. Other countries not only have a protocol, but are also researching and gathering evidence about treatments that help patients recover. Nothing like that is being done here. Patients here are admitted to hospitals and aren’t even asked about their contacts or about their family, neighbors or friends.

Unfortunately, it must be recognized that Nicaragua’s health system isn’t responding to our people’s health needs, it’s responding to a political “command and control,” as is seen even in the death certificates. Doctors are ordered not to write “suspected COVID-19” or “presumed COVID-19,” because if they fulfill their legal obligation to tell the truth, they will be fired or threatened with having their medical license or code revoked, a pressure with no legal foundation.

Why so many speedy burials?


From the epidemiological point of view, any death from pneumonia today is suspected COVID-19 unless proven otherwise, so I wonder: if, as is written on the certificates, so many are dying of pneumonia and not COVID, what’s the point of all the speedy, almost clandestine night burials? Such burials are only justified if the bodies are highly contagious, which can only be the case with three possible diseases: cholera, which we don’t have here; Ebola, which doesn’t exist anywhere in the Americas; or COVID-19.

We’re already experiencing not the official pandemic of the figures but the real one of family suffering. Even if the government doesn’t give the real, up-to-date number of cases, we are increasingly learning them directly. We are starting to know more infected people and more people who have died, but only the gravedigger will be able to tell us how many dead he has seen buried each day.

Projections of the infection curve


The health professionals warned us that 60 days after the first recognized case—on March 18 here, so May 18—we would see the contagion curve begin to climb, but we’re already seeing it before then. What we’re seeing so far, however, is nothing compared to what is coming, based on the experience of other countries. This March, various sources made projections for Nicaragua: the Central American Business Administration Institute (INCAE), Imperial College London, Dr. Álvaro Ramírez and others. The lowest projection estimated almost two million people would be infected, 30% of the population, while the highest estimated four million. Hospital admissions were estimated at between 77,580 and 368,054 cases and for those in intensive care at between 18,403 and 38,790. Estimated deaths ranged from 24,000 to 69,000.

All these calculations are from two months ago and the study with the highest figures was based on the assumption the government would institute no mitigation measures. If we had the real data, we could begin to see how exact the projections are. These mathematical models are used because they enable us to see the future quite accurately and try to prepare. Those made for Spain proved very precise.

In other countries the curve rises, peaks and then falls in about two months but in our case it could be extended because of the government’s decision to encourage crowds. Our epidemic curve will thus surely stay higher for longer, even several months longer, with those infected by others continuing to come in waves. As a result, when the epidemic is under control in the rest of Central America, there will still be more human and economic attrition here than in those neighboring countries.

The responsibility in facing
an epidemic or disaster


Those coordinating to deal with an epidemic or disaster should train frontline staff, giving them the best tools, preparing them and preparing to support them with all the necessary logistics. Here we’ve seen none of that.

In March we were told there was no need to be alarmed or concerned because the health system was ready to care for us, but reality is now telling us that wasn’t true; there was not only no organization and no serious prevention or even mitigation plan—and still isn’t today—but also no plan to prepare the health services for what was coming; until mid-May they were even putting patients suspected of having the virus together with those who didn’t. Furthermore, health workers began attending to the first people infected without any personal protection. Medical and nursing students were also sent to attend to infected people in hospitals without being given any protection. In fact doctors and nurses were even prohibited from using masks and gloves, so as not to “alarm.” This is profoundly irresponsible. Not only does it endanger them but also puts them at risk of infecting other patients and their own families, friends and neighbors.

Where’s the protection equipment for healthcare workers? Where’s the logistics? Why are there already more than 60 of the health staff infected as of mid-May, according to the Citizens’ Observatory? Why do we have five doctors on intubation today? It’s blatantly apparent that there was no preparation and, consequently, the human damage will be incalculable.

Right now there are two gravely ill doctors in León’s teaching hospital, one of whom continued teaching class to numerous students until he got too sick, while the other, a surgeon, continued operating every day. I wonder how this could possibly have happened. Were these doctors unaware of the seriousness because the health system didn’t make explain the symptoms or did it perhaps make them feel obliged to keep working?

They told us to stay calm because there were 19 hospitals ready to care for those infected, but they didn’t even say which they were and today there are people who don’t know where to go. Furthermore, most of the best equipment in those hospitals isn’t in Bluefields, Bilwi or Estelí, it’s in Managua because even though the virus can infect anyone, access to healthcare in Nicaragua isn’t equitable. It depends on social class and economic possibilities, and also on partisan political contacts. As always, it’s the poorest of the population that uses the public health system and thus be the ones who will be the most affected.

Distrust in the health
system has been growing


There are people who don’t want to go to any health unit because they don’t trust the system due to all its negligence. The public lost confidence in the health system a long time ago, but their distrust increased after the April 2018 crisis, when public hospitals received orders not to attend to those wounded in the anti-government protests. Many died or were disabled because of doctors who obeyed that inhuman order. Distrust has been increasing even more as the epidemic is growing because it has made the lack of credible information and preparation apparent. This is very serious because some infected people can overcome the disease on their own, but others need to be cared for in the public health system.

In addition to not taking preventive measures and telling us there are enough hospitals ready (the Pan-American Health Organization even came and certified that claim), we were also told that the lauded “family and community health model” would work here effectively, referring to those house-to-house visits by the health staff. But, those making the visits could infect those they talk to or vice versa by not taking precautions, maintaining social distancing, wearing masks or plastic face shields. In short, these visits may have been one more contagion mechanism.

These house visits aren’t a “model,” they’re just an “action” and one that should educate by example. Those health brigade workers, government officials or members of the ruling family can’t talk about social distancing as a fundamental prevention measure because they themselves go around together in a tight little group, not keeping any distance. All those making house visits may also say the right things, which I don’t know, by not practicing social distancing they are at a minimum setting a bad example.

What has this regime invested
in health over its 12 years?


The government has built infrastructure, improved some hospitals, put air conditioning in waiting rooms, etc., but patient files are still hand-written and most are illegible. We should have them computerized because that would facilitate accessing information and, consequently, enable us to provide better prevention and care. I have offered MINSA free collaboration for computerizing the files for years, but they haven’t been interested, even though it is vital for research and for improving quality and services.

The best investment in health is improving the quality of medical professionals. Those of us who studied medicine and have a passion for it must continue studying every year of our lives, as it is an art and keeps changing at great speed; that of four years ago is no longer that of today. In Nicaragua there’s been no investment in medical quality. More has been invested in guaranteeing millions of medical consultations but of what quality? And who can ensure that quantity is accompanied by quality or that the quantity of consultations improves health? Furthermore, if we don’t train professionals with open minds, and if they work in an institution that doesn’t accept being criticized, there won’t be quality.

After the events in April 2018, 400 doctors, nurses and health staff in the public system were fired for thinking differently from the government, some of them highly specialized professionals of internationally recognized quality with 30 or more years of training. Firing them was a very serious mistake. By doing so MINSA deprived the population of access to the specialized treatments they are entitled to, and for which these doctors have been trained. I’ve been told that due to the pandemic MINSA is hiring people in several departments because of staff shortages and because many professionals are getting sick.
This abundant source of excellent doctors is there, and they should be rehired; not to do so is as huge a mistake as firing them.

Science, not political speeches


The pandemic, like any epidemic or disease, is solved with science, not with political speeches. In times of an epidemic, a doctor doesn’t just treat a patient; s/he treats the whole population and must do it with the utmost quality. What has been clearly shown with this pandemic is that MINSA responds to political guidelines, not to science. In the health units we see more signs with political messages when what are needed instead are more signs talking about the need for vaccinations or, now, how to wash hands properly and other mitigation measures.

The government has invested in some technological infrastructure, but the latest technology doesn’t guarantee medical quality, just as the best computer doesn’t guarantee a good writer; it only facilitates writing. The investment in medical technology has improved care, but prevention—which is more urgent—remains marginalized even though it requires very little technology. For example, cervical and uterine cancer is the main cause of death among women in Nicaragua and it is 100% preventable. In a health system like ours, with the community-based model we claim to have, how is it possible that this disease still hasn’t been controlled and continues to kill women, who are the backbone of our society? This cancer is so “noble” that it gives us eight years to find and examine a woman for precancerous cells and treat those with heat or cold and prevent the cancer from developing. It’s an example of effective prevention that prevents deaths and doesn’t need high technology. Technology isn’t the only or even best way to guarantee medical quality.

Health care providers are mistreated


It’s the obligation of the public health system to take care of its people. Nicaraguan doctors are the worst paid in Central America. A general practitioner who works all shifts can earn $700 a month. This isn’t right, we must improve their salaries and also those of teachers, the two most important professions in any country. But it isn’t just the money; it’s also how they are treated.

I know good doctors who have resigned, left the public sector due to pressure and mistreatment from the pro-government unions, which don’t respect them as doctors. All’s well and good for those from the governing party, but for those who aren’t it’s very bad.

In addition to serious failures due to not having implemented prevention campaigns and not having reorganized the entire health system in preparation for the pandemic, another serious failure has been not relying on all the actors in society. When we talk about a pandemic we’re talking about a disaster. In all the Central American countries, all of them, the first thing the governments did was unite all the state institutions and summon the national anti-disaster system to get ready to act. Not even that was done here.

Nor have all the media been considered. Each one has its followers; none reaches everyone. In the 1980s we gained a lot of experience in dealing with epidemics and we always worked together. In those years La Prensa wasn’t well regarded by the government, but its reporters were as comfortable entering the Ministry of Health as the pro-government reporters seeking information. We gave all of them information because we knew that those who read the FSLN’s Barricada didn’t read La Prensa. We knew the need for campaigns to reach everybody and to do that we had to involve them all.

What’s needed in a pandemic is an ongoing prevention-based educational campaign, led by MINSA, that reaches everyone, in this case teaching how the virus works, how it is transmitted, and how it is dealt with, constantly repeating that contagion is basically avoided by keeping a distance of more than five feet from other people and not touching one’s eyes, nose or mouth if one’s hands aren’t well washed with soap and water. Soap is the key because this virus has a lipid layer that is destroyed by even the cheapest soap. The campaign must also teach what to do if symptoms appear because most people get what appears to be a light flu from the virus and it has to be explained what to do at home without having to go to the hospital.

Why is Costa Rica doing
better than Nicaragua?


In addition to Costa Rica having taken the appropriate measures and taking them progressively, it must be kept in mind that for decades Costa Rica has invested in mass education of quality for its children. Nicaragua has wide educational coverage but the quality is poor. Costa Rica’s population has a much higher level of schooling than Nicaragua and a level of professionalism far superior to our own.

The Costa Rican population’s educational base enables the health system to do what we can’t do here, and both the health system and its epidemiological surveillance system have a history of high quality. The country has a well-developed scientific sector, because the State awards scholarships based on technical criteria while here we award them based on partisan political and family criteria. The Costa Rican health system has credibility among its population, while here we say our system is the best and not even the population believes in it. Furthermore, the Costa Rican public and private health systems work together with public policies aimed at supporting the most vulnerable, and there’s up-to-date information on the Health Ministry’s webpage about how the pandemic is progressing. All this makes a tremendous difference when confronting a disaster of this pandemic’s magnitude.

In Nicaragua, complicating things even more, we’re entering the pandemic progression curve and the rainy season at the same time. Without a campaign for preventing COVID-19 or the other epidemics there are in the country—pneumonia, diarrhea, leptospirosis, dengue, malaria and other diseases—they will skyrocket with the rains. We could face what is known scientifically as a “syndemic,” which is when several epidemics come together at the same time, combining symptoms with COVID-19 in what could be an even more deadly combination.

We must work together


The Interdisciplinary Scientific Committee—which we created in late March, gathering together professionals from various medical, educational and psychological specialties—invited all social sectors and the government to sit down with us so we could advise, support and work together. We have met with everyone except the government, which hasn’t responded to us. We continue to insist that we must work together, however, because this can’t be controlled alone. We must work together.

We still don’t have a Medical College in Nicaragua, because they put a “lock” on the law that says the Ministry of Health has to call a general assembly of doctors to choose which ones will organize the Medical College over a two-year period, and we know this will never happen with this government.

We also don’t have real medical unions. The Sandinista Doctors’ Movement and FETSALUD, the FSLN’s health workers’ federation, should have been the first unions to demand protection equipment for health workers, but they did nothing; on the contrary, union members took masks away from doctors who had bought their own. What’s the point of a union that doesn’t protect its workers?

In every country, all non-urgent surgical operations were cancelled to focus efforts on dealing with the pandemic. Nothing is as urgent as controlling COVID-19. Whatever their specialty, all the doctors in the world, whether neurologists or orthopedists, are today treating COVID-19. We’re all doctors and, knowing the protocol, we can treat those who get sick. We do have medical associations for general practitioners and for the different specialties in Nicaragua. We got together and produced a 200-page guide in which each specialty made its own protocol for treating the pandemic. Let’s hope MINSA makes use of it.

I can only hope that concern about controlling this pandemic unites our country. What we have achieved so far is to unite the medical sector, with perhaps one exception. We have joined together the medical associations like never before. We’ve all worked at a speed never seen before to produce the protocols and guidelines. We’re also all working to find protection equipment for health workers and we’re doing it together. We’ll continue working, each in what s/he knows and can do, each in his/her own field, but all leading to the same goal. The pandemic has united us a lot to each other and to the rest of society through our efforts to educate the public via accessible media. This is a tremendous achievement at such a difficult time Leonel Argüello Yrigoyen is a general practitioner specializing in epidemiology. He worked for the Ministry of Health for over 10 years in the 1980s and since then has directed national and international NGOs. He now heads the NicaSalud Federation Network.





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