By Coleen Littlejohn – May 27, 2023
Nicaragua, the third poorest country in Latin America, has a population of approximately 6.7 million people but has the most extensive and well-equipped public health system in Central America. Since 2018, Nicaragua has had a pharmaceutical plant with the capacity to produce 12 million influenza vaccines per year and plans to produce antiviral drugs, such as Interferon Alfa/2B, and Covid vaccines. The National Reference Diagnostic Center is one of the pioneer laboratories of molecular biology in Latin America, second in the region. Recently, the government inaugurated the first medical oxygen plant in the region. Health care is free. A study in May of 2021 by the World Health Organization and Oxford University included Nicaragua among the ten safest countries for travelers in relation to Covid 19. So, it should be no surprise that Nicaragua has dealt successfully with the Covid 19 pandemic. Though that is not what you would have read in the international press during the pandemic.
I have lived in Nicaragua since early 1980, arriving only a few months after the July 19th, 1979, triumph of the Sandinista Revolution which overturned a US backed dictatorship installed in the mid 1930´s. Twenty days after the triumph, the new government declared that free health care and education were human rights for their people. The country had what I used to call a “honeymoon” for almost two years with the building of new schools and health clinics, a national literacy campaign that substantially reduced illiteracy and the introduction of a national community-based health system, starting with training community-based health volunteers, known as “brigadistas.” The honeymoon was short lived. At the opening of the Literacy Campaign Museum in Managua in late 1981, the very first images were the pictures on the wall of the more than 40 student literacy brigadistas who had been murdered by the counter revolutionary forces financed by the United States, known as contras. The end of the war was negotiated in 1989 and elections were held in 1990. The US backed opposition won because it was made very clear that, if they did not win, the war would continue. The neoliberals remained in power until 2007, when the FSLN returned to the presidency via elections, and today, 17 years later, many of the dreams of the Revolution have become a reality or are well on their way.
One of those dreams has been the development of a Family and Community Health Model. Since 2007 Nicaragua has increased the number of trained health professionals from 22,083 in 2006 to 36,649 in 2020. In 2006 there were 2,715 doctors, and in 2020 – 6,045. There are now 1,565 health facilities and, since 2007, the government has inaugurated 24 new hospitals with high technology equipment and the necessary medical specialists. Another 15 hospitals are under construction or are planned. Natural Medicine is now part of the system: 315 clinics throughout the country offer alternative and complementary therapies, guaranteeing a comprehensive healthcare system with cultural sensitivity. There are now 181 maternal wait homes (casas maternas), up from 50 in 2006 for women from rural areas to live and get medical attention for two weeks before their due date. They are located close to a hospital or health clinic where the women will give birth. There are now 15 centers for psychosocial needs and a National Center for Child Mental Health. Other special programs include Love for the Smallest, a national program for children at risk for malnutrition or who need early childhood stimulation, as well as Everyone has a Voice, a special program that attends over 189,000 people with physical disabilities.
Nicaragua began to prepare for the Covid pandemic even before Covid was declared a Public Health Emergency of International Importance on January 30, 2020. An inter-institutional commission was established to ensure a coordinated and comprehensive approach to fighting the pandemic and, on February 9th, the Ministry of Health (MINSA) issued a joint protocol with the Pan American Health Organization (the branch of the WHO in the Americas) for the preparation and response to the risk of Covid 19 to ensure adequate surveillance and early detection of suspected and confirmed cases. Nineteen hospitals were identified to specialize in Covid 19 cases, of which one in Managua would address severe respiratory diseases. Among other resources, at the start of the crisis, these hospitals were equipped with 562 intensive care beds and 449 ventilators. The protocol also included greater preparation of primary care health units for addressing respiratory symptoms at a national level, training of 36,000 public health workers and of private personnel, and the acquisition of protective equipment.
Special emphasis was placed on increasing contact tracing capacity. Before the first case was detected, MINSA intensified its vaccination program to reduce the level of other respiratory diseases such as influenza and pneumonia that would make the fight against Covid more difficult by using similar health resources. 158,000 volunteer community health brigadistas, together with personnel from MINSA, made over five million home visits (about four visits per household) all over the country to make an updated local census, taking note of people over 65, people with chronic illnesses, children, and to discuss with each household the basic measures of prevention. They also completed a national nutrition census, measuring the height and weight of children under six, approximately 1,386,32 boys and girls, to identify families that might need additional nutritional support for their children.
MINSA also organized 66 mobile clinics to attend to rural areas that were identified as more vulnerable. Another key part of the strategy was to train 9,000 people to monitor the 19 points of entry to the country used by visitors or Nicaraguans returning to their country. Unofficial but known crossings were also monitored. A free hotline with 150 operators was set up to attend both cell and landline telephones for people to request assistance and advice. There were 110,000 calls in its first month of operation. With respect to public transport, a daily disinfection program was carried out in 10,000 public buses and 23,000 taxis as well as in more than 10,000 schools and 130 open markets of high volume in Managua. Disinfections outside of the capital were twice weekly.
Before the first case was detected, President Daniel Ortega addressed the nation to update all on what the government was doing and to announce that the country would not close down despite the pressures to do so from neighboring countries. In a country where about 80% of jobs are in small businesses, small farming, or in the informal sector, the government faced a dilemma. Should it confine people to their homes, knowing that most would lose their incomes and their capacity to feed their families? How would the 40% of Nicaraguans who live in rural areas survive if not able to sow their crops, given that the peak of the pandemic coincided with one of the main planting seasons. The country had already suffered an almost total lock down less than two years earlier when, in April of 2018, well financed opposition groups, initially using student protesters in front of a Jesuit University, accused the government of not doing anything to put out a fire in a natural forest reserve. When that didn’t spark a response, the accusation changed to accuse the government of obeying IMF recommendations to implement cuts to social security benefits. That also did not work. Social media was then flooded by fake news of massacres which convinced some that this was true. A second round of well-organized attacks in major cities and towns started almost immediately. By mid-July, peace was restored but over 200 people were killed, including 22 police officers. Damages to the health sector included 18 buildings damaged, including four hospitals, two regional health offices and one maternal waiting home invaded and looted. One hundred seven MINSA vehicles were destroyed, 15 totally and 92 partially; these included new ambulances and mobile clinics. Medical equipment was destroyed as well as medicines robbed. Nicaragua’s economy, which had been growing on average at 5% per year (third highest growth rate in Latin America) was severely damaged by the events of April to July 2018. Growth dropped to minus 4% in 2018 and minus 3.9% in 2019.
It was clear that the challenge of designing a national Covid response in Nicaragua had to consider not only fighting against the virus but also preventing, to the extent possible, another blow to the economic recovery and development efforts of the government. Nor did the government close public schools or universities, although there were no sanctions or penalties if families chose not to send their children to school. Nicaraguan public schools also offer free lunch to all students, and during that pandemic, in poorer areas, that was increased to two meals a day. Private schools did close, but most of their students were technologically equipped for online classes. Today it is very clear that both Nicaragua’s decision to not close down the economy and the strategy to contain Covid were the best for the country. By refusing to lock down, the government saved the country from economic disaster. Nicaragua’s economy has recovered swiftly from the pandemic, with GDP growing by more than 10.3% in 2021 and 3.8% in 2022.
The most critical months of the pandemic were May to July of 2020 when it was more than clear that Nicaragua was into the phase of community transmission. Exact numbers of cases were always difficult to calculate, because, as a WHO report had indicated, 80% of infections were mild or asymptomatic, and therefore not counted if no test had been done. MINSA decided to only count cases that had been confirmed by positive PCR RT testing given that pneumonia and other illnesses also normally affected death rates. By August of 2020, numbers were gradually falling, although they peaked again in mid-2021. The weekly report of April 25, 2023, stated that 15,679 positive cases had been detected in Nicaragua so far. Of these cases, 15,443 individuals have recovered, 245 have died and 9 remained active and undergoing responsible medical treatment. WHO later reported that Nicaragua had one of the lowest rates of excess deaths during the pandemic. MINSA’s efforts were complemented by the great majority of people and businesses in the country who followed MINSA´s recommendations. In general, Nicaraguans were doing more to protect themselves by wearing masks and ensuring they kept physical distance and by applying systematic hygiene measures at home and in public and private establishments. While tourism came to a halt and hotels and restaurants closed, many other businesses and outdoor markets stayed open with precautions in place.
Nevertheless, MINSA and the government’s efforts came under constant attack by a vast campaign of the opposition in Nicaragua and abroad to discredit the government’s efforts to address and control the pandemic. Opposition media spokespeople and never-heard-of-before private medical associations scorned the government’s efforts to control the pandemic and accused the government of negligence. They deliberately sowed fear and suspicion among the population so that, at first, some people were not only terrified about the virus but also of using free public health services that were available, resulting in more severe illness and, in some cases, death. International media continued to severely criticize Nicaragua’s response to the pandemic, parroting the local opposition media. Even as the pandemic subsided in Nicaragua, the Washington Post (8/8/20) was calling the government’s response “bizarre and dangerous.” The Financial Times (10/4/20) reported Nicaragua’s Covid statistics in October but gave the impression that the number of cases were part of a “worsening economic and social crisis.” And in February of 2021, the Guardian criticized Nicaragua’s “stumbling response to the coronavirus pandemic.” The government decided to combat the misinformation campaign and published a 75-page report describing its strategy to tackle COVID-19 and assuring the population that accusations of a health system in crisis, of hospitals collapsing etc. were just not true.
What was true, however, is that because of illegal coercive measures, aka sanctions, Nicaragua did not initially receive support from the usual sources of financing from two major multilateral funders, the World Bank and the Inter-American Development Bank and, when support finally came, it was later and much less than given to other countries, despite Nicaragua being recognized as one of their top clients in terms of transparency and project results. When the WHO-supported vaccine sharing began, Nicaragua received a limited amount from a donation from India and other countries and began vaccinations, giving priority at first to people over 65 and those hospitalized or with chronic conditions, and then more widely as more vaccines came in via WHO or other country donations. At present, 99% of the population of Nicaragua has been vaccinated against Covid, the highest level in Latin America.
Nicaragua was not alone though. Just as when the Revolution triumphed in July of 1979 and Cuba immediately came to Nicaragua’s assistance, the Henry Reeve Brigade of Cuban doctors, virologists, epidemiologists, and intensive care specialists came to Nicaragua to share their Covid and other disease protocols and the catalogue of medicines that they were using in Cuba and other countries where they were helping. The Brigade also did a national diagnostic of the primary attention component of the health system in Nicaragua.
Nicaragua’s popular heath care strategy over the years enabled the successful experience in dealing with the Covid pandemic but it is also very important to summarize other long-term factors that have contributed to the continuing development of the country that enabled the health system to work very efficiently and effectively. These include the following:
- Excellent macro-economic management of the economy starting in 2007 when the government began to formulate National Development Plans which have been updated every four years. The latest (4th) is for 2022 to 2026. Priority is given to health (22.2%) and education (23%) in the national budget. The InterAmerican Development Bank recently ranked Nicaragua as 2nd in Central America and fourth in all Latin America in health investments.
Achievements in development and health statistics from 2006 to 2021 include:
- Development of basic infrastructure throughout the country. The country is connected. Nicaragua has the best roads and road maintenance in Central America, including new highways to the Southern Caribbean Region (Bluefields and Pearl Lagoon) and, just recently, to the Northern Caribbean Region, to Bilwi. The existence of an extensive paved road system and continuing investments in increasing access to water and sanitation, electricity, and communication technology make it possible for medical teams, equipment and supplies to be mobilized quickly. National communication system (phone, cell and internet service) are available in 85% of the country, compared to 30% in 2007. Now 99.4% of the population has electricity compared to 43% in 2007; 75% of energy is renewable (wind, hydro, geo/thermal, and bio/mass. Ninety-three percent of urban households have piped water compared to 65% in 2007. In rural areas, 55% have piped water compared to 26.7% in 2007.
- Development of a highly efficient national disaster prevention and mitigation system, SINAPRED: In the last two years, there have been three major hurricanes but, due to excellent preparation and the capacity to quickly reach the soon to be affected areas, very few people lost their lives, very different from the case in neighboring countries.
- Nicaragua has achieved 92% food self-sufficiency via programs for small farmers and cooperatives.
These are the reasons why most Nicaraguans have faith in their government´s capacity to confront pandemics and to manage the economy in general. Long gone are the days when epidemics of polio, diphtheria, measles, whooping cough, etc. affected the population and especially children. There were areas of the country in 1980 that had never seen a doctor or nurse, especially in parts of the Caribbean Coast. I remember being contacted by a missionary nun in Waspam who told me that children were dying in a small Miskito community on the Rio Coco, and no one knew why. It was diphtheria.
Nine years ago, I was working in Liberia, West Africa and lived through the Ebola epidemic. What was ever present in my mind during that time was the conviction that if Liberia had also been supported over the years in developing a community based public health system with sufficient internal infrastructure and public services for her people, which is the case of Nicaragua, thousands of lives would have been saved in both Liberia and Sierra Leone. Ironically, the same thing could be said for the United States, where more than a million people died of Covid 19. It should only be a matter of time before Nicaragua’s effective response to the pandemic is internationally recognized, especially as it is in such contrast to most other countries.
Time will tell.
mforinocohttps://orinocotribune.com/author/mforinoco/September 23, 2023
mforinocohttps://orinocotribune.com/author/mforinoco/September 16, 2023