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  Number 476 | Marzo 2021
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Nicaragua

Year one of the pandemic

COVID-19 vaccine donations are beginning to arrive in Nicaragua. There are far from enough but so far they are being put in priority arms. This look at the country’s first year of the pandemic recalls different moments, offers disputing figures, even the best-intentioned of which are unreliable, and describes how both the people and the government have dealt with it. As the rich countries engage in the race between mass vaccination and the possibility of a new variant that is more resistant to vaccines, Nicaragua must rely more on people’s own responsibility. What are our chances?

Envío team

March 18 marked one year since the first COVID-19 case was detected in Nicaragua. In that time, officialdom irresponsibly and persistently concealed the truth about the disease’s development in the country. It pushed the image of a prepared and efficient health system and a normality maintained without requiring lockdowns, thus ruling out the chance of any type of economic assistance, even though some sectors, particularly tourism, have been hard hit.

What the first surge was like


Neighboring countries applied numerous measures both internally and at their borders, which in some cases were questioned as excuses for increasing authoritarian crackdowns. The Ortega government, however, like its US counterpart at the time, applied its authoritarian tendencies more perversely. Both denied the seriousness of the pandemic, eschewed masks and politicized their use. While Trump repeatedly held crowded super-spreader political rallies of maskless supporters in state after state, Ortega and his wife ordered one massive entertainment event after another, hoping to attract tourists, but mainly reeling in their own supporters, thus putting them at the greatest risk.

As envío reported in its June 2020 issue, carpentry shops cranked out coffins all day long, and rows of holes were dug in cemeteries throughout the country, particularly in Masaya, Managua and the port city of Corinto in Chinandega. The worst thing in those first months was what were quickly dubbed “express burials,” conducted in the dead of night.

In the era of social media, government secrets are harder to keep. News of the burials soon leaked out, and many were filmed on cell phones. The videos showed Ministry of Health (MINSA) officials, “dressed as astronauts,” as some described them, taking coffins to cemeteries in vehicles guarded by parapolice. No relatives were allowed, which was naturally considered disrespectful, cruel and even inhuman.

“Why at night?” was a question many asked back then. Nicaragua is admittedly a poor and tropically hot country with few morgue facilities, and autopsies are not commonplace. This is why the deceased are typically buried the day after the wake, but do not explain these unceremonious and immediate secret burials. Such precaution would probably have seemed appropriate if the government had acknowledged the surge of COVID-19 fatalities, but made no sense when the death certificate read “pneumonia.”


A curious surge of “excess mortality”


A study comparing death certificates in Nicaragua for 15 years (2005 to 2019) with those of the first surge of the pandemic (March-August 2020) revealed an “excess mortality” in that six-month period. The rate increased significantly, to 120 deaths per 100,000 inhabitants, when the norm in previous years was 25.5 to 29 per 100,000. With the figure starting to soar in March when the pandemic arrived in the country, that is the only possible explanation of the phenomenon. The notable statistical increase of deaths in those six months was officially attributed to different types of pneumonia, diabetes, heart attack, hypertension and other chronic pathologies, but all of them are vulnerable to COVID-19. Most if not all of those deaths were surely caused by the virus, although the government and the Ministry of Health do not recognize it in their reports.

According to Dr. Carlos Hernández, the public health specialist in charge of the study, “there is an underreporting of 7,800 deaths up to August 31, 2020, that are attributable to COVID-19. There were actually 49 deaths for every death reported by the Ministry of Health in those months. Taking into account the excess mortality, the underreporting is 98%.”


he year’s facts, figures and fictions


MINS has never released the number of tests it has performed, and there are no other sources of information, as it is the only institution that is allowed to do them or has the proper kits. Since the beginning of the pandemic, MINSA has been charging US$ 150 for a PCR test and only does them in one place in the country, the Health Ministry’s main center in Managua. With people originally forced to come back in person another day to receive the results, the crowds were huge and disorderly, making the site an infection hotspot. Fortunately, this process was later made more efficient and thus safer.

By the end of the first year of the pandemic, MINSA recognized only 6,582 cases of COVID-19 and only 176 resulting deaths. Unlike testing, however, it is not the only source for figures on infections and fatalities. More credible ones have been provided on a weekly basis by the Citizen Observatory on COVID-19, created at the beginning of the pandemic. It relies on independent reports from professionals in various related disciplines. For the first full year of such monitoring, it has documented 13,237 presumed cases of infection, of which 884 were among health personnel. (The term “presumed” is necessary because the government still forbids listing the cause of death as the virus on death certificates, and because independent testing is not possible). The virus-caused deaths reported to the Observatory over the year have totaled 3,008, 116 of them health personnel. If those figures are relatively accurate, the illness-to-death ratio is an alarming 22.7%.

For purposes of a rough comparison, neighboring Costa Rica, which has a population of 5.1 million compared to Nicaragua’s 6.4 million, has recorded 230,000 cases, with the number of deaths almost identical to those reported by the Observatory in Nicaragua (an illness-to-death ratio of 1.3%). Given Costa Rica’s better health institutionality, including more testing and early application of precautionary measures, it is not illogical to assume that even the Nicaraguan Observatory’s case figures are underreported.


Meanwhile, the regime fiddles


Over the year, government spokespeople have repeatedly spent their energy sending out novel messages with a positive, albeit erroneous spin. For example, last May, when the regime was taking particularly heavy heat for the hands-off way it was dealing with the pandemic, Ortega’s policy adviser Paul Oquist tried to peddle nationally and internationally a 75-page government “white paper” justifying what it called its “unique strategy,” supposedly based on Sweden’s model, itself now widely recognized as a failure. (It was reported on April 13, the very day this issue closed in English, that Oqist had died of COVID-19.)

The Vice President has also been responsible for some gems. In the middle of last year, she was interviewed by the pro-government media following a presidential briefing in which Ortega lauded Nicaragua’s health system and again tried to fob off the rising deaths as caused by pneumonia. Unable or unwilling to articulate a strategy, she blamed international scientists for having different positions on the pandemic, and ended by counseling the viewers to simply trust God.

Once Russia had announced that it had come up with a vaccine, she announced that a pharmaceutical plant built by the Russians in Nicaragua would produce the vaccine here and distribute it throughout Central America. While a Nicaraguan engineer quickly set the record straight (the most this factory is equipped to do, he said, is fill the vials), a wave of relief swept through Managua. In many local neighborhoods, people prematurely abandoned their masks, believing safety was just around the corner.

Since October 13, the government has systematically disseminated the exact same figure of COVID deaths in its weekly report: one.


Civil society fills the government’s shoes


While the Citizen Observatory has assumed the task of keeping the population informed of the pandemic’s advance as accurately as possible, the Multidisciplinary Scientific Committee (CCM), also created in response to the pandemic, advises people on the measures they should take—and those they should steer clear of—to defend themselves against it.

The CCM brings together a large number of physicians and other health-related professionals who have treated those infected and attended to their families and the population in general. They have kept themselves abreast of the constantly updated knowledge worldwide, and provide daily information to the population through the independent media and social networks. Without the efforts of the Observatory and the CCM, the population would have faced this health crisis blindly and with much greater fear and negative results.

Now all supermarkets and most stores catering to the middle and upper classes in Managua and other major cities meet customers at the door with a digital thermometer and a spray bottle of alcohol applied to both hands and carts. They also enforce mask-wearing and social distancing at checkout lines, as do government institutions serving the public. Popular open-air markets are less inclined to go to such trouble and expense; only some of the venders and customers even wear masks.


Nicaragua does have a
few comparative advantages


It must be admitted that Nicaragua has some relative factors in its favor. It is the largest country in the region with a population density of only 55 per km2, compared to Costa Rica’s 94 per km2. The Costa Rica capital’s population density is 6,455 per km2, compared to only 3,900 per km2 in sprawling, earthquake-wary Managua, with its few elevatored high-rises. Both countries’ tropical climate permits year-round outdoor living, although Nicaragua’s greater poverty forces more multigenerational overcrowding in homes.

While tough on Nicaragua’s young tourism industry, the few commercial flights have been coming to Nicaragua this past year has likely spared the country more imported new virus strains. In the first months, that was due to the bad press of the government’s pandemic denial policy, and more recently because the government has demanded tedious passenger test-verification procedures from airlines, which most have found bureaucratically unacceptable. Only the Colombian airline Avianca now flies from the United States.


Will recent history repeat itself?


In December, independent experts begam warning of a probable second surge of coronavirus infections in Nicaragua, in part for the same reasons as the surges elsewhere in the world: relative disregard for the dangers of big extended family gatherings in December and huge crowds at the beach in March.

Part of the cause, however, continues to be the government’s erratic messaging. While personnel in government institutions that attend to the public Nicaragua’s population, including public health centers, now usually—but not always—wear a mask, the government has never ordered anything approximating a lockdown, even in those first months. And while private schools and universities quickly moved to on-line teaching early in the pandemic, public schools, never suspended in-person classes. It must be said that the results of on-line teaching have not been encouraging, and parental and other pressures have led most private education centers to either segue to a hybrid system of part on-line and part in-person classes or to completely reopen.

A particularly grievous example of government negligence is that protocol to prevent the spread of the pandemic was not followed either during the evacuation of victims of the two huge hurricanes that slammed into the northern Caribbean Coast in early November or in the overcrowded shelters. Neither masks nor soap and water for hand-washing were available. The Red Cross reported treating 315 cases of COVID-19 during its humanitarian assistance to those in the shelters. These figures, too, are much higher than those provided by the Health Ministry.

Even though one more frequently again hears mention of personally knowing someone with COVID, Nicaraguans seem to have wearied of mask-wearing and social distancing, both of which have become less and less common on buses and on the street. This is particularly the case among poorer, less-educated sectors, which are reasonably dubious about the danger of something as invisible as a germ. Even those who try to follow recommendations from the independent social media sometimes don’t quite get it. A case in point is a young woman in Managua who sells cheese from a stall in front of her house. She dutifully tosses the bills and coins she receives as payment into a bucket with some alcohol in it… then without another thought uses the same hand that has accepted the money to cut more cheese for the next customer.


Vaccines are starting to arrive


Have people lowered their guard because the vaccine is actually coming to Nicaragua? On December 13, the Vice President reported that the government would assign US$115.7 million to purchase three types of vaccines (the Russian Sputnik-V, and those from Oxford-AstraZeneca labs), as they are appropriate to the country’s type of refrigeration equipment. She did not specify how many doses this would buy or when they might arrive. No more thas ben said.

Meanwhile, as one of the 10 poorest countries in Latin America and the Caribbean, Nicaragua, together with Bolivia, Dominica, El Salvador, Grenada, Guyana, Haiti, Honduras, Saint Lucia, and Saint Vincent & the Grenadines, is eligible for a donation of free COVID-19 vaccines from the COVAX mechanism. This is an initiative of the World Health Organization (WHO) and the regional Pan American Health Organization (PAHO), financed by the wealthier member countries. On February 1, PAHO confirmed that it would send 500,000 doses, without stating any dates.


Three weeks later, the first batch of Sputnik V vaccines arrived in Nicaragua, a donation of 6,000 doses, which were given first to patients with chronic renal insufficiency and then to those suffering from cancer and cardiac problems. The hospital or health center treating them was in charge of giving them a specific appointment to receive the vaccination.

Initial confusion becomes a success story


Then in March, a reported 335,000 doses of PAHO’s first shipment of Covishield vaccine arrived from India’s AztraZeneca laboratory. At first it was not explained to the population how the vaccination plan would proceed, either by age or by territory, nor was there any accessible presentation in the media of how, where and when anyone could get access to the vaccine.

Dr. Hernández, who led the 15-year study of death certificates, stressed that a vaccination plan must repeatedly inform the population about how vaccination is progressing and what its phases will be. “We request that the vaccinations not be politicized,” he urged, “because it is a matter of life or death. The politicization of the pandemic itself created a lot of mistrust and this creates barriers of hesitancy to vaccinations.” Critics say that in an election year, the Ortega-Murillo regime, so discredited by its handling of the pandemic and its violent response to the April 2018 rebellion, is using the vaccine campaign to boost its image.

In an April 5 article in The Guardian, the president of the Nicaraguan Medical Association, Josefina Bonilla, explained that “there should be a plan that follows PAHO’s recommendations, laying out the priority groups according to risk,” adding that “doctors and health workers still haven’t been included—there is no news of vaccines for them.”

Within days of that article, the news had spread, apparently unofficially at first, that the PAHO donation was dedicated to people at least 60 years old, as well as younger people with less critical chronic diseases that make them particularly vulnerable to the effects of COVID-19, such as diabetes and hypertension. Neither health personnel nor teachers were prioritized.

The government then quickly made it official, and published a list of public health centers and hospitals where the vaccinations would be provided. At first it was chaotic. One who went to one of the five centers in Managua that first day, in this case a hospital, arrived at 9:30 am, and didn’t finish until 5:30 pm. By the closing date of this issue of envío, a week later, the time had been reduced to three hours in the Managua health center we observed. It and the other four were averaging more than a thousand people a day. The efficiency of the process, which involved taking basic data on the person, including any COVID-vulnerable illnesses, taking the person’s blood pressure, entering it all into MINSA’s computerized system on the spot, the injection itself, and then a wait of up to a half an hour. People with physical disabilities of any kind were fast-tracked. The hundreds of people being moved through the stages at any given time were seated outside under canvas awnings with no social distancing but there was a light breeze and everyone wore a mask. The efficiency and kindness of the health personal put us in mind of the selfless human mobilizations of the early|1980s in campaigns that reduced illiteracy from over 50% to 13% and eradicated polio. There were reports of political proselytizing by governing party activists in some centers, but there was none where we were.


Where do we go from here?


Nicaragua has the advantage of having a young population, so with luck thee COVAX donation might be enough to cover the two shots for all those over 60 who choose to get vaccinated. But the possibility of vaccinations for the millions who are younger is an open question.

The populations of Nicaragua and other poor countries are not as fortunate as those of wealthy countries, where the race is more neck-and-neck between achieving herd immunity through massive vaccination campaigns and another upsurge of COVID cases that could produce a more vaccine-resistant mutation. The only protection for Nicaraguans is to keep their guard up, protecting both themselves and each other. In this election campaign year, what are the chances?


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