and equipment, an intelligent system of referrals, a setup for primary and secondary and tertiary care.” Alan Greenbaum is a trauma unit nurse at Harborview Hospital in Seattle who spent two months in early 1986 working at La Trinidad Hospital, about 130 kilometers north of Managua. Greenbaum is an organizer for the Committee for Health Rights in Central America (CHRICA), a group which is working with Partners for Health to raise money for a new truck and clinic building for Hospital Fernando Velez Paiz in Managua and for the Acahualinca Clinic. RECYCLE SUPPL IES AS MUCH AS POSSIBLE . T H E Y TAKE USED RUBBER SURGICAL GLOVES AND RE STER IL IZE THEM T IM E AFTER T IM E UNT IL THEY HEY’RE SHORT OF EVERYTH ING. THEY “They’re short of everything,” says Greenbaum. “They recycle supplies as much as possible. They take used rubber surgical gloves and re-sterilize them time after time until they just fall apart. We collect supplies and used equipment for them, from hospitals, doctor’s offices, individuals here in the U.S.: EKG machines, defibrillators, slit lamps for eye operations, spectrophotometers, autoclaves, sterile gloves, needles, syringes, tape, gauze, orthopedic equipment. But while individuals and organizations express their solidarity with the Nicaraguan people, their government and tax dollars underwrite a multi-pronged campaign to unseat the revolution. The U.S. trade embargo which began in 1985 has had a dramatic impact, for until that time Nicaragua bought and sold more EALTH POL ICY HAS FOCUSED ON PR IMARY CARE , AND HAS REL IED ON TH E URBAN AND RURAL POOR THEMSELVES . A BOU T HALF OF TH E HEALTH CENTERS AND POSTS BU ILT SINCE TH E REVOLUTION W ERE CONSTRUCTED BY LOCAL COMMUN ITY GROUPS . goods here than with any other nation. This has been coupled with support to the ex-Somocista Contra forces, which have forced the diversion of most of Nicaragua’s meager resources to the defense effort. “Actually, there’s been very little improvement in health care over the last couple years,” Greenbaum notes. “The priority is the war; everything goes for that. The economy is in a shambles. Inflation is out of hand. In just the two months I was there inflation almost doubled. A lot of people have turned from productive work to some kind of unproductive hustling just to survive, selling fruit on the streets of Managua, for example, instead of farming. Everything is in short supply.” Dr. Jorge Garcia experienced similar problems. He worked for three weeks in Condega, a small town in the northwestern mountains only about 25 kilometers from the Honduran border. “We had a crippling scarcity of simple imported materials, such as paper. We took empty sacks of Canadian flour, cleaned and cut them to wrap up surgical gloves for re-sterilization. I wrote prescriptions on pieces of newspaper, between the lines. We had no penicillin, or medicine for parasites. We dispensed only ten aspirin at a time.” .Ad tacks on health facilities and personnel have been a major focus of Contra activity. In the first four years of the Contra war, 63 health units have been put out of service because of Contra attacks, including one hospital, three health centers, and 59 health posts. Many of them were bombed and burned, and others had to be closed because of war-related population movements or vulnerability to attack. Doctors, nurses, and brigadistas have been captures, wounded, killed, tortured, raped, and in some cases kidnapped to Honduras. “During my stay in Condega 21 people were killed by the Contras," recalls Dr. Garcia. “Two were members of the malaria control project. Another was a 56- year-old paramedic. The Contras particularly targeted health care workers and clinics. I could not visit certain communities because the trails were too dangerous. I was additionally at risk for being a foreigner. Just before I left, a platoon of Contras gang-raped and severely beat four German women who had been vaccinating children against polio. Two were in critical condition.” According to the Nicaraguan government, about a third of all non-Contra war casualties are civilians, and more than half of these are children under the age of 15. Much Contra activity seems to be indiscriminant, and simply aimed at terrorizing the population. “ I remember treating one eight-year- old girl who was wounded in a mortar attack on her house,” says Dr. Garcia. “ She had second- and third-degree burns on her back, and her mama held her awkwardly up on her shoulder so her back wouldn't be hurt. Every day she came to the clinic for treatment. We would have to spend up to an hour and a half treating the burns, peeling off old skin, applying the ointment, the bandages. It hurt terribly, must have seemed to go on forever. “One morning a pickup truck appeared at the clinic. Two boys lay in the back covered with blood. The older one was unresponsive and pale. We placed him on a stretcher and ran into the clinic. His pulse was rapid and weak. He took shallow breaths. We put intravenous lines in both arms, poured in two liters of saline, and elevated his legs. Still no blood pressure, and he stopped breathing. I began mouth-to-mouth resuscitation. He lost his pulse. We began chest compressions, then he vomited and was dead. Just 16 years old. His nine-year-old cousin had a smaller wound in the leg, and a bullet in his shoulder. He grimaced with every movement as we removed the burnt flesh and coagulating blood, and then treated the wound. But he never cried out or made a sound. I don’t know whether he kept his leg. JUST FALL A PA R T .” “Later, a truck arrived with the bodies of the three who had died in the attack—the grandfather, Pedro Villareine; his son Ramon, and his eight-year-old granddaughter. They had been shot in many places and were drenched in blood. The small girl lay on a stretcher, her skull smashed by a bullet. “This family of farmers lived in a small village near Condega. Shortly after dawn they were ambushed by a platoon of Contras. The family had two guns, relics of their war against Somoza. After their am- munition ran out the Contras came, found seven people s t ill alive, and marched them to Honduras. Some of the family had hidden and survived. “The survivors of the war are victims also. There was a woman whose family had all been killed, she was the only one left. She wandered in a daze for months, not understanding what happened. In Nicaragua people get old at a very early age. The sad thing is, war has now replaced diarrhea, malaria, and other infectious diseases as the number one cause of death.” W n e thing that struck me was how much they’re torn between wanting a U.S. style medical system and one that makes sense for Nicaragua,” says Dr. Dajer. “They even believe a U.S. doc is better than a Nicaraguan doc, just because of where he’s from. Given the limited resources of a poor country, a health care system based on preventive medicine is especially appropriate. It requires a low level of technology and a small amount of money. But medicine by definition requires technology if it’s going to be diagnostic and curative, and that’s the essence of U .S . med ic ine ., h ig h ly individualized, high-technology. “ I guess I thought I’d go down there and everyone would be very enlightened,” says Dr. Dajer. “They’d all betaiking about the evils of western medicine. But they want the evils of western medicine! Part of it is a revolution in rising expectations. These are people who yesterday had no health care, and now they see it as their right. The same poor peasant who never saw a doctor before 1979 is now in your office saying, ‘What do you mean you don’t have time to see me today? Screw y o u ! ’ ” What is needed in Nicaragua is a medical system adapted to the particular needs of the vast majority of the Nicaraguan people. The U.S. medical system, highly techno log ica l and ind ividualist as it is and geardd to the profi t a b i l i t y of the m a jo r in s u ra n c e companies and health care provider organizations, cannot be the model for Nicaragua. “The biggest job of all is to change people’s ideas,” says Dr. Dajer, “to convince people that the U.S. model isn’t the right one and neither is the Cuban model, which ironically has much in common with U.S. health care. When you make a mass public health care system from scratch you lose quality. You’re not going to have superspecialists in their little cubicles in Managua dispensing high quality medicine, and for rich people and those who could afford it, that’s a loss.” Medical students are not chosen now just because their parents have enough money to send them to an expensive school. Many of them now come from oeasant and working class backgrounds, and they are chosen for their enthusiasm for serving people and taking part in the mass public health campaigns. Medical students are taught to think of themselves as public health workers. During the summers they work in hospitals and clinics and rural health posts, making beds, emptying bedpans, sweeping floors. Nicaragua has made an impressive beginning in breaking the hard ice of exclusivism and elitism in which the Nicaraguan medical system had been frozen for so many years. Now the challenge for the revolution is to continue building on this foundation in the face of the ongoing, U.S.-armed and funded opposition. Nicaragua must draw from the knowledge and skills provided by outside medical personnel while discovering and shaping the system most appropriate to its own needs and economic limitations. One thing has changed permanently. Nicaragua is now a land of hope. Andrew Hines is a writer living in Seattle. 48 Clinton St. Quarterly
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