THEALTH CARE IN N ICARAGUA The Seattle Connection By Andrew Himes P h o to s b y J o rg e G a r c ia I n 1968, Antonio Dajer was a small boy in the land of no hope, a Nicaragua of sorrow, disease, and endless hunger. Dr. Dajer is now a family practice doctor at the University of Washington Medical Center. “ I was born in New York,” he says. “ I did most of my growing up there, but both my parents were Nicaraguan. We had strong family ties there, so we went back for long visits several times. “What I rerpember most was the poverty. Beggars would come to the door and my mother would fix them a plate of food. You’d go to the countryside and there were these little hovels that people lived in and children with bloated bellies from starvation. I thought, this is a country without hope, people will always be poor. The place was so depressing that at the age of ten I was plotting my escape. I was going to run away back to New York, I was going to go on up the Pan-American Highway and get back to the U.S., somehow, some way. “ That’s one thing they don’t really grasp, all these people who are going to Nicaragua now. The contrast. The difference. Before 1979 nobody ever went to Nicaragua. You would see only poverty, depression, misery. There was no reason to go. All the Somocistas knew that nothing would ever change, and even the anti- Somocistas knew that nothing would change, ever.” 1/oday, however, some of the most remarkable changes have taken place in the health care system. Within a few short years Nicaragua went from being one of Latin America's “health basketcases,” as one observer put it, to having the U.N. World Health Organization name N icaragua the Third World’s “model country” in health care. Many North American health professionals are taking a deep interest in Nicaraguan medical affairs. Seattle in particular has provided substantial medical assistance to the new Nicaragua. Seattle’s Sister City status with Managua, Nicaragua’s capital and largest city, has provided official cachet for the relationship. Within the last few years, more than 100 Seattle area doctors, nurses, pharmacists, and medical administrators have gone to Nicaragua as visitors or as volunteers in health care facilities. “The poorest country in Central America used to be the sickest,” reports Dr. Steve Tarnoff, a physician at Group Health’s Rainier Medical Center who travelled in Nicaragua in 1984. “That has changed and part of the success of this emerging health-care system is nonmedical; it’s an obvious change of morale. The government is trying to make the people healthier and they know it. I think pride has a lot to do with the incredible cooperation at the most grass-roots level. In Nicaragua you see tremendous poverty, but you don’t see squalor.” Dr. Antonio Dajer returned two years ago to a Nicaragua which was no longer a country he’d known. “ It was like they had unleashed this fresh spring which was being held back by Somoza, and some very natural things were able to take place. People were taking care of themselves, and cleaning things up and getting shots for kids.” H e a l t h conditions in Nicaragua und^r the Somoza regime were abominable by any standard, even worse than in most of its Central American neighbors, according to a report in the New England Journal of Medicine. Thirty-five percent of the urban population and 95 percent of the rural population lacked access to potable water. The Sandinista government estimates that 90 percent of medical services were directed to 10 percent of the population. More than half the doctors and medical beds were located in the capital city. Malaria, tuberculosis, and parasitism were endemic in much of Nicaragua. One-third of the people contracted malaria at least once in their lives. Measles was a great killer of children. In malnourished children, measles may be accompanied by an overwhelming and often fatal bacterial pneumonia, usually of staphylococcal origin, and recent studies indicate that up to two-thirds of chilT HE POOREST COUNTRY IN CENTRAL AMERICA USED TO BE TH E SICKEST . T H A T HAS CHANGED AND PART OF TH E SUCCESS OF TH IS EMERG ING H EA LTH -CARE SYSTEM IS NON -M ED ICAL ; IT’ S AN OBVIOUS CHANGE OF MORALE . THE GOVERNMENT IS TRYING TO MAKE TH E PEO PLE H EA LTH IER AND TH EY KNOW I T . ” dren were malnourished. Life expectancy at the time of the revolution was only 53 years. Infant mortality was estimated at between 120 and 130 per thousand (compared, for example, with Panama’s purported rate of 30 per thousand). Dr. Jorge Garcia, a volunteer for two months in 1983 at a war zone health clinic in northern Nicaragua, now works as a family physician at a clinic for migrant workers north of Seattle. He just completed specialty training at Group Health Cooperative in Seattle, and was a founder of Partners for Health (PFH), an alliance of Group Health consumers and employees which has established a sister clinic relationship with Acahualinca, a clinic serving 7,000 residents in one of Managua’s poorest communities. PFH is working to raise money to build a badly needed new clinic building. “Nicaragua had some big problems to tackle," says Dr. Garcia. “ First they set out to deal with hunger and malnutrition, to distribute food, especially to children and nursing and pregnant women. They trained almost 30,000 public health workers, they call them brigadistas, that’s almost 10 percent of the population involved in some form of health care. They set out to immunize people, especially children, thousands of whom died every year from easily preventable diseases like polio, bacterial diarrheas, tetanus, measles, whooping cough, and malaria. They wanted to provide care to anyone who was sick anywhere, so they set up these health posts and clinics everywhere in the rural areas. They trained midwives, paramedics, people to give inoculations. They undertook some badly needed health education. For example, traditionally, after a woman had a baby her only food for a month or two was tortillas and a drink made from corn meal [ato/e], a te rrib le diet for a nursing mother—no protein, no calcium.” Health policy has focused on primary care, and has relied on the urban and rural poor themselves. About half of the health centers and posts built since the revolution were constructed by local community groups. Eleven national health campaigns for sanitation, immunization, rabies control, first-aid training, and malaria control have been held. Polio has been eliminated, measles and rabies have nearly disappeared, and other vac- cine-preventable infections have been greatly reduced. Advances like these in a poor, formerly disorganized country under military and economic attack are truly remarkable, especially when contrasted with neighboring Honduras which, despite enormous U.S. financial and technical assistance in recent years, has made little progress in public health. “That’s why I get excited about Nicaragua,” says Dr. Dajer. “ I talk to friends, docs and medical students who go to other Latin American countries where life is generally short, nasty, and brutish. They go to Guatemala, Honduras, Colombia, Brazil; they come back and say: I pushed pills, I have vitamins, but as soon as we leave it’s the same old crap, things will never change. But in Nicaragua there’s a chance to be a part of something that might actually change things.” A d i the accomplishments of the revolution, though, seem easy and simple compared to the tasks that remain, in the face of Nicaragua’s poverty and the ravages of the Contra war. “One thing I was struck by,” says Dr. Dajer, “was how difficult it is to create a health system when you have nothing. Coming from the U.S. I just assumed that if you organize something, and if the right people are making the decisions, then you’ll have adequate health care. No problem, you just redistribute the resources rationally and adequately, no sweat. Well, that’s not true. You do need resources. You do need training and management skills, you need supplies Clinton St. Quarterly 47
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