The health system’s many pending issues

Following last month’s assessment of Nicaragua’s public education, this issue offers an assessment of its public health system, focusing on the most important holes that the next government still needs to fill to respond to the population’s urgent needs, especially those of women and children.

Ana María Pizarro

I have been participating in Nicaragua’s public health system since 1981 as a student, an intern, a doctor in
social service, a resident doctor, a community doctor and a teacher. Along that road I was able to learn how the health system worked in the most remote communities, the municipal health centers, Managua’s general hospitals and the Bertha Calderón women’s hospital, where I had the opportunity to direct the Intensive Care Unit in the last years of the revolution. During all that time and right up to today I’ve researched health issues using the information generated by the public institutions. Based on those experiences and with the conviction that a country’s public health always has political dimensions, I’d like to reflect on the evolution of our health system and on the issues still pending to respond to the population’s demands, with special emphasis on the female half of that population.

The health care model
during the revolution

We had an extraordinary health care model during the revolution, put in practice by Great Britain. It was a universal model, which assumed that everyone had the same risks of contracting illnesses and that the system must respond by providing the entire population with all the care possible.

But that system was totally unsustainable in a poor country like Nicaragua, which to make matters worse was being attacked and destabilized by a US-financed war. In those years we experienced a huge contradiction: on the one hand we had rescued health care as a right of all people and established the State’s concern to bring health services to all communities, but on the other there was a noticeable shortage of human and financial resources and the health system itself was wracked with limitations.

In that same period the idea that everyone has equal health risks was being discarded throughout the world, replaced by the risk focus theory, which teaches that each person has different risks of contracting different illnesses, depending on sex, age, surroundings, occupation, education, sexual practices, race or ethnicity and economic condition. Risk focus positively discriminated according to people’s probabilities. We learned there are different risks and illnesses for men and women, children and adolescents, adults and the elderly. In 1987, at the Safe Motherhood Conference in Kenya, the world made an important shift to focus health care on the different needs of different populations. That was when the term “comprehensive health” began to be heard. Risk focus encouraged the development of specific programs, which started up in Nicaragua toward the end of the eighties.

The Cairo Conference:
A watershed

Years later, in 1994, the Cairo Conference on Population and Development established development as a fundamental axis of governmental activity and women as an indispensible motor force of that development. Humanity was moving forward, taking Nicaragua along with it.

The concept of development was analyzed from different angles in Cairo. For years an increased birth rate had been promoted to recover the population lost during wars. More recently overpopulation was defined as the cause of poverty in Latin America, Asia and Africa. With that, the power centers started pushing for birth control, controlling women’s bodies either through forced sterilization or the mass promotion of contraceptives for women.

Cairo denounced both views and put a halt to the controllers and the abuse of women’s bodies, raising reproductive rights to the category of analysis. It broke with the patriarchal mandate that women’s only mission is maternity, stating that motherhood must be freely elected and lived in optimum conditions. It spoke of men’s reproductive responsibility and warned about adolescent pregnancy and the AIDS epidemic.
Cairo marked a watershed in that it transformed health systems all over the world, establishing the concept of people’s comprehensive health. While it was at it, it called for a better distribution of wealth between the rich and poor countries.

Nicaragua’s official delegation in Cairo was headed by then Minister of Education Humberto Belli and by Élida de Solórzano, both of whom waved the Vatican banner, opposing virtually anything that had to do with women’s rights. Nicaragua was one of only nine countries that opposed the majority view of 184 countries, and regrettably Nicaragua’s delegation acted with incredible belligerence.

Women filled the gap with alternative services

With the revolutionary process halted abruptly in 1990, some of the progress we had made was also halted. Nonetheless, we were visionary women and had already begun to innovate, convinced that the public health system was an unwieldy and incredibly complex machine that it was difficult if not virtually impossible to change from within. With the new concept of comprehensive health, Nicaragua’s organized women instituted two extremely interesting initiatives that have never been properly recognized.

First they created maternity centers. The first ones appeared in the final years of the revolution, thanks to the work of internationalist feminists who came to Nicaragua with very efficient models already experienced in Africa; they were supported by many Nicaraguan solidarity committees. It should be said that the Ministry of Health was late coming around to the maternity center concept: not until 1995, when they were already functioning and providing an extraordinary service.

The other important initiative was the creation of alternative centers to provide comprehensive health services to women. Some were founded at the end of the eighties and a larger number in the early nineties, always at the initiative of feminists, most of us also Sandinistas, who understood the need to provide an alternative health model for women.

With the end of the revolution
came the privatizing of health care

We have to recognize the efforts made by the international community to institutionalize Nicaragua in the nineties, with the end of the revolution. The legislation, codes and organization of a State with coherent functioning and a separation of powers was very positive; all is at risk now.

But alongside those advances was the decision to privatize public health care and education, and the international agencies and donor community governments also helped set up all manner of legal machinery to achieve that.

Public health care remained privatized until 2007. It involved opening private service areas in the nation’s public hospitals, which produced a huge distortion in the system, since private care was being provided in public installations financed by the public budget and run by public officials. Health personnel were increasingly willing to work in the private services even during the graveyard shift, but reluctant to attend the poor patients who came to the free public section.

Later other clinics appeared, strictly to attend to the small minority of Nicaraguan workers who are covered by social security. These private companies work with a business logic, allocating very limited amounts to treating the insured workers, which means the clinics function with major limitations.

In health, what had been a public obligation and a universal right thus became a service geared solely to the “vulnerable population”—as the model established it. As a result, the new model contained an enormous contradiction. According to the World Bank, 83% of the Nicaraguan population was poor in that decade. Now they say it’s 63%. If 83% was poor and thus vulnerable, it meant the public health system had to be available to virtually the whole population, or at least the immense majority. And it never was.

Government-civil society communication
offered us at least minimal input

When the Cairo Conference and the following year’s Beijing Conference on Women promoted the concept of “women’s comprehensive health care” as a universal model, it opened the way for coordination in Nicaragua between the women’s movement focused on health and the health system authorities. We can’t say that coordination achieved a whole lot, but it did establish communication channels that worked to some degree. Those channels included the National Health Council, a huge lumbering unwieldy elephant; the National Commission against Maternal Mortality and the National Anti-Violence Commission. The more recent National Economic and Social Planning Council (CONPES) also had a Health Commission we were able to participate in until January-February 2007, when the current government dumped the civil society organizations that had sat on it previously.

Those first years after the revolution were characterized by a huge mobilization of the social organizations. We formed networks and commissions and participated in the different levels of mixed civil society-government arenas where decisions were being made and were at least invited by the government to hear our opinions, although we had no way to ensure that our proposals would be incorporated in any evident way into the laws, policies or programs.

One of the pending issues:
Real input from civil society

In legal terms, Nicaragua has always been a very chaotic country. Sometimes we have a national plan but no law, while at others there’s a public policy but no plan. Not until 2002 did we finally get a General Health Law, preceded by a weak consultation of civil society. Men and women of civil society involved in all spheres of health spent many hours thinking together, offering contributions and writing chapters, only to suddenly discover the law was already at the printer’s.

It needs to be recognized that this way of acting, which amounts to a farce, was characteristic of the “participation” processes of the nineties. Civil society’s real possibilities of transforming the state institutions’ approaches were extraordinarily limited. And that’s still one of the pending issues. All governments in Nicaragua, the current one included, have repeatedly missed the opportunity to take advantage of the participation and contributions of organized, talented and proactive women’s and civil society organizations.

The General Health Law rubber stamped the privatization of health care initiated years earlier. Its regulatory law was a tool that indicated how to privatize and how to apply the neoliberal policies, right down to the last stratum of the health system. By the time that law was drafted we no longer had any way of participating.

One health plan after another,
and we rejected them all

During the nineties and until this government took office we also saw the preparation of a new National Health Plan every five years. We organized women publicly rejected the plans of the Chamorro, Alemán and Bolaños governments. I recall the last one, that of the Bolaños government, being widely disseminated, even presented to around 3,000 people in an auditorium, with the government bringing in health workers from all around the country to receive it. Women’s organizations working in health and feminists received it with flyers, banners and a pronouncement arguing that it would do nothing to reduce maternal mortality. We managed to persuade the police and conference ushers to let us enter the event with our banners, so we could deliver our own proposal to the diplomatic corps and government ministers. Nothing came of it, but what we did then would be unthinkable today.

Not until late 2006, at the end of the Bolaños government, did we finally get a National Health Strategy. It was drafted by Dr. Maritza Cuan, who worked as a consultant, and published in November 2006, at the end of that year’s electoral campaign, continuing the tradition of all outgoing governments to rush around during the electoral period presenting results. For the first time we had an official document that clearly mentioned sexual and reproductive rights, as well as respect for sexual diversity, and referred to abortion as an especially serious problem for the poorest women, who have less access to health care. But the strategy was short-lived. When the Sandinista National Liberation Front (FSLN) won the elections, it appointed Dr. Cuan health minister and that’s as far as that good document got; it’s not applied today at any level of the health system.

Recognition of violence
as a public health problem

There were also some important ministerial resolutions in that whole structure of laws, plans and strategies that was created in the nineties. One very important one was issued in 1996 by the Chamorro government’s Ministry of Health, typically in search of the women’s vote only a month before her administration ended. The resolution declared violence a public health problem, which is a concept laden with meaning. But we can’t say it ever had any real and concrete application in the health system’s services, given the way the cycle of violence women experience is progressing and what the public health institutions should be doing but aren’t to help them break out of that cycle.

A comprehensive health model with a risk focus implies the creation of specific programs. And in the nineties the Ministry of Health was enormously strengthened with health care programs based on that focus. People’s characteristics were identified to take into account the possibilities of their contracting certain illnesses, and that translated into policies aimed at information and prevention for a specific sector.

Religious fundamentalists don’t
recognize the State as secular

But what advanced at that time had to retreat later. A good example was the Ministry of Health’s publication of a national sexual health and reproductive health program at the start of the Bolaños administration. It was a very simple document to help all the ministry’s units apply a series of procedures related to sexual and reproductive health. Although the program’s contents didn’t directly refer to sexual rights and reproductive rights, it occurred to someone to use those words in the prologue. That earned the program a frontal attack by fundamentalist Catholic and Evangelical organizations that went on for three months until the Health Ministry finally had to withdraw it. It tried again two years later and failed. In the end, the program was transformed into a guide “on love and sexuality,” drafted with the bishops’ consent.

In 2003, in response to pressure organized by these same fundamentalist groups, President Bolaños also had to withdraw a sex education manual the Education Ministry had worked on with United Nations support. These were moments in which the religious hierarchy’s determining influence on public health and education was clearly expressed, overriding the constitu¬tional mandate that Nicaragua is a secular State.

Focus on adolescents

In the midst of this panorama were programs for the prevention of HIV-AIDS, malaria and other infectious or contagious illnesses. Work also began on a comprehensive health care model for teenagers. To that end adolescent centers were opened in the municipal and national public hospitals. Although they had the best of intentions toward the young population, particularly those at risk, the focus was very adultist and the model wasn’t very successful.

The social organizations, particularly women’s organiza¬tions, also got involved in this issue, creating adolescent education and health care centers. Characteristic of all these years was the combination of a structural crisis in the public health system and a major mobilization of civil society, which organized to provide alternative prevention and treatment models.

The criminalizing of therapeutic abortion

In 2003 Nicaragua was moved by the pregnancy of Rosita, the nine-year-old daughter of an emigrant Nicaraguan family who was raped in Costa Rica, with neither country willing to terminate her pregnancy. The case gave women’s organizations an opportunity to participate actively in denouncing her treatment, providing information, dialoguing with authorities and defending the girl’s rights, until finally her pregnancy was successfully terminated.

This case generated a debate in society on the meaning of therapeutic abortion, legislation that had been on the books in Nicaragua since 1837. Over time since then, the different penal codes had expanded the flexibility so that first midwives, then druggists and doctors were no longer subject to prosecution. Nicaragua survived two national wars, invasions, the Somoza family dictatorship, Liberal and Conservative governments and the Sandinista revolution, and never in all that time did it occur to anyone to eliminate that legislation. Nonetheless, following the opening implied by the Cairo Conference, Vatican-guided Catholic pressure groups began working all over Latin America to eliminate any possibility of terminating pregnancies. Nicaragua was no exception.

A coalition had been formed in Nicaragua in 2001 for the express purpose of abolishing therapeutic abortion. Within five years it succeeded, when in the heat of the 2006 general election campaign the National Assembly fast-tracked a request from the Catholic bishops to eliminate it. The petition was endorsed by thousands of churchgoers, many of whom didn’t grasp the meaning of what they had signed. With barely 20 days from start to finish, a legislation that had survived 171 years was stricken from the books. The FSLN, which actively supported its abolition, assured its membership it had done so only as an electoral tactic, and would reinstate the legislation once it won the elections in 2007. It has never even attempted to do so.

The elimination of therapeutic abortion made Nicaragua one of only 5 countries in Latin America and 17 in the entire world in which there is absolutely no legal possibility of ending a pregnancy under any circumstance. Nearly 180 countries permit abortion in at least some situations.

Free public health services return
and yet another model is introduced

Since the FSLN took office in 2007, it has reestablished the principle of free public health services and implemented a change of discourse, again bolstering the concept of health as a right of the entire population, which had been eliminated by the three previous governments.

And of course the health care model changed again. The new one, known as the “family and community health model,” was presented at the end of the government’s first year in office. Conceptually this put Nicaragua back into a stage prior to the revolutionary years, given that the family isn’t a homogeneous entity, as it can contain babies, children, adolescents, adults and the elderly, males and females. Each family is a unique world requiring differentiated health care models from the State. Furthermore, women’s specific needs and demands disappeared with a return to the maternal reproduction conception.

The model’s goal is very similar to that of the revolu¬tionary years, meaning that it is equally expensive to sustain. It requires lots of resources, as well as an infrastructure that Nicaragua doesn’t have and that hasn’t been reactivated to the degree and with the speed the model requires.

Different models, never enough budget

As we’ve seen, Nicaragua has jumped from one model to another, each applied in the midst of contradictory realities. The one common denominator has been that the public health budget has always been insufficient.

With only 17% of the population—the economically active workers in the formal sector—having access to health services covered by social security and roughly another 8% relying on private medicine because they can afford to do so, a full 75% still depends on the public health system. While the discourse, access and supply of services has improved with this government, the worrying part is how to make all of this sustainable.

Let’s look at that budget over the past three years. In 2009 the Health Ministry received 4.09% of the gross domestic product (GDP). In 2010 it was 3.8% and in 2011 3.6%. It grew 5.8% between 2008 and 2009—the first budget prepared by the FSLN government itself—but fell 2.8% between 2009 and 2010 and another 0.6% between 2010 and this year.

Putting it in numbers, net health spending in 2009 was US$257 million; in 2010 it dropped to $249 million and in 2011 it dropped a bit more to $248 million. But we have to remember that the annual population growth is 2.8%, making per-capita spending $44.70 in 2009, $42.90 in 2010 and $42.10 this year.

Current spending, the ministry’s day-to-day operating costs, has risen notably in recent years without similar growth in capital spending, in other words investment in infra¬structure so the country can respond to the population with better installations. In 2007 the budget inherited from the Bolaños administration allocated $44.7 million for capital spending and $169 million for current spending. This year capital spending fell drastically, to only $12.1 million.

All these figures are published by the Central Bank, the only state institution that periodically reports on the current situation. They indicate the serious tensions affecting the health system, with the government talking about its determination to resolve the health problems but not actually prepared to do so.

Thus we have official propaganda that encourages the population to go to the public health institutions for free services, while at the same time the government isn’t allocating the needed resources. This triggers an ongoing contradiction that’s resolved only by the sacrifice of the health personnel, who are constantly pressured to live up to the official discourse, but have neither the equipment nor the supplies needed, much less the time or installations.

Pros and cons of the current government model

I want to identify other contradictions in the current model, as well as some major gaps that should be prioritized by this or any other government. These contradictions and holes have frequently been identified by the women’s organizations around the country working at the grassroots level with women, youth and the population in general.

1. No respect for the civil service law. This government has repeated a negative tradition of the three previous ones, which is a failure to respect Nicaragua’s civil service law. Public officials trained in health care during the Sandinista revolution were expelled from the state institutions during the Chamorro government. And when Alemán came into office he expelled officials from her government, a practice then repeated by Bolaños and by the current government in 2007. This eternal change of health personnel is very serious because it means the country stays at square one no matter how many years pass.

2. No updated health information. Let me next say something basic: we have no official information from the Ministry of Health. One example: even in this age of computer information, the latest updated sheet of the ministry’s epidemiological bulletin is from May 2008. It has been three years since routine monthly statistical information has been available to the public as it was in previous governments. Although the quality wasn’t great, that information did allow us to analyze the course of the health system in all its dimensions and programs.

3. Medical brigades aren’t a solution. Another problem we’re seeing with the current model, which seeks to propagandize successes at any cost, is the medical brigades, which are sent to remote areas to provide medical services to the rural population. I remember how much work it took in the eighties to coordinate a medical brigade: preparing the equipment, pulling together the personnel, coordinating vehicles, bad weather, impassible roads…

Months ago I was talking to female health personnel from the North and South Caribbean who are today participating in these brigades—over 90% of the brigade members are women—and they were telling us they feel exhausted and under pressure; they had lost many weekends, which had affected their relationship with their families; they had to sleep on the ground, were eating poorly and were afraid of the violence and sexual harassment they frequently had to deal with. Why are brigades needed? Because the health system has no presence in many outlying communities.

In the evaluation we did in the Caribbean they also told us the brigades are now going out much less often; the resources they work with have been cut and many communities just have to wait, sometimes with emergencies that end up not being treated. What ought to be a priority, especially if the government claims it’s reaching the entire population, is an ongoing state presence in all communities. But the budget isn’t big enough to make that a reality.

4. Nondiscrimination for sexual options, but also no appropriate care. This government published a ministerial resolution establishing that people will not be discriminated against for their sexual option. Prior to that, in late 2009, it created an Ombudsperson’s Office for the Human Rights of Sexual Diversity. Both measures represent a notable cultural advance. This government has thus sent out positive messages to people who don’t follow the norm of compulsory heterosexuality imposed by the patriarchy, which could amount to at least 15% of Nicaragua’s total population.

Despite the political and electoral propaganda surround¬ing the issue, however, we see that in practice the health personnel totally lack the kind of knowledge required to provide appropriate care. Although the law no longer penalizes homosexuality, which is a great step forward, the State isn’t prepared for this challenge within either the educational system or the health system. Nor is it trained to be familiar with and respond to this population’s specific needs.

5. Alcohol, tobacco, drug and junk food abuse needs to be addressed. Alcoholism is an epidemic that is socially tolerated and celebrated in Nicaragua; it’s even encouraged and perpetuated by constant advertising. Yet no prevention or education campaigns are related to alcoholism, or even to nicotine addiction or drug abuse. A few years ago millions were spent in Nicaragua to prevent German measles, with a campaign that took information to the country’s most remote districts. But there have never been prevention campaigns to reduce the ravages of alcohol, tobacco or drugs. Nor are there enough campaigns or any sustained public effort to improve the diet of people who today eat so much junk food.

6. Violence against women inadequately dealt with. Let’s now turn to other, even more serious problems. In the first place, violence is a health problem for women, and given its magnitude, it’s also a public health problem. We at least have some access to data on this issue, provided by the National Police’s special stations for women and children, one of the extremely few state institutions that still publish a statistical yearbook. According to the latest data from the 2010 yearbook, these police stations received 34,700 charges of violence, 90% of it against female adults, adolescents and children last year. It should be pointed out that these stations don’t record all charges, because if the violence leads to the victim’s death it is dealt with by the National Police, not the special stations.

Analyzing how charges of violence are classified, we see that 60% are defined as misdemeanors and only 40% as crimes, which leads us to deduce that the vast majority of those responsible for violence are never punished or even tried. Of the 40% classified as criminal offenses, 11% are defined as domestic violence, 10% as sexual crimes, 4% as other crimes, 9% as violations of freedom of action and 3% as offenses against property.

Extreme violence against women is growing. Between 2001 and 2010, the murders of 729 women were recorded, an average of 72 a year. So far this year, at least 69 women have already been murdered, although the Police only records 29. What we’re seeing is that the health system isn’t interested in specifically addressing the cases of women who die violently at the hands of their partner or spouse or survive with aftereffects.

7. Rape is also a serious public health problem our health system has yet to deal with. The United Nations Population Fund reported 14,000 girls raped in Nicaragua in the past 10 years, many of whom ended up pregnant. Their pregnancies were treated as high-risk, but the Health Ministry paid no heed to the fact they were the product of rape. That’s extremely serious and aggravates the prejudices and wrongs caused by the health system’s new priority since the abolition of therapeutic abortion—that all these girls have to give birth.

We believe the first and most elemental measure that must be assumed is to provide morning-after pills to avoid pregnancy among girls, adolescents and in fact women of any age who’ve been raped. But these pills aren’t on the health system’s basic list, even though they are on the protocol stipulated by the World Health Organization at a world level. Second, it must be presumed that any raped girl or woman may have acquired HIV, and she must consequently receive immediate preventive treatment.

8. Not all maternal deaths are recorded. Another of the problems related to women’s life and health is maternal deaths. We know there are maternal deaths that aren’t officially recorded. We have an extremely expensive recording system in Nicaragua. It has cost the donors a lot of money and different experiments have been conducted since 1990 to improve it. Right now we can’t tell if it’s functioning well or if the international classifications are being applied because we haven’t had access since 2007 to the statistical system on either the health system in general or women’s health and maternal deaths in particular.

In personal research, I found that the deaths of twelve pregnant women in 2003 were never incorporated into the maternal mortality rate. The same was true of four women in 2004, ten in 2005, seven in 2006 and sixteen in 2007. In other words, I learned about nearly 50 pregnant women whose deaths weren’t included in the maternal mortality record; they were classified as suicides because they died from having ingested insecticides, pesticides or other strong poisons. We know those deaths had to do with unplanned, unwanted pregnancy and were directly linked to the prohibition of abortion [only therapeutic abortion was legal in Nicaragua before 2006; abortion on demand has always been illegal] Over 80% of the women who took their life that way were under 16 years old.

9. A good goal wrongly applied for the wrong reason. Following the criminalizing of therapeutic abortion, this government has widely propagandized its successes in reducing maternal mortality. But the strategy employs procedures that often violate women’s rights. We have the testimony of women, especially in Matagalpa, that the Councils of Citizen’s Power (CPC) [a governing party organization that operates on the grassroots level] hounded them to attend “prenatal control.” They are often forcibly taken by ambulance to receive treatment at maternity centers and thus avoid later complications that could alter the successful results the government wants to present. Their husbands or partners are frequently threatened with arrest if they prevent the woman from going to the centers. We know of women who, with no medical justification, are forced to remain there for two and even three months, leaving behind their home, children, animals and vegetable gardens. Some escape because they can’t bear being so far from their home and community. This procedure has also stretched the maternity
centers’ already limited capacity.

Such party pressure to achieve glowing government statistics is damaging what is a good objective and distorting the rationale of the maternity centers, which are such an effective method for women in any country with a rural population. A good goal, such as reducing maternal deaths, becomes questionable with procedures of this sort. We also know of adolescents who receive positive results from health system pregnancy tests and from then on are besieged by the CPCs to discover whether they are planning to continue the pregnancy or make another decision. I don’t know if the CPCs are receiving some sort of training to provide proper health care. I applaud the contribution any organization makes to improve the health of its community, but that organization needs to be trained, and in the case of the CPCs, we’re seeing that party orientations take precedence over training.

10. Penalization of therapeutic abortion applied to the max. Among the crimes filed in the women’s police stations, we’ve also found charges of abortion. This means the new Penal Code approved in 2008, which retained the criminalization of all forms of abortion despite the FSLN’s promise to change it, is being applied to the max and in the greatest silence. Not until this year did we realize charges had been filed against women for the crime of abortion in the women’s police stations. Since therapeutic abortion was made illegal, 91 women have been accused of abortion, and 36 men have been arrested for it, most of whom were charged with beatings that resulted in a miscarriage. In other words, they were arrested for abortion and not the violence they exercised against the women.

11. Emergency obstetric treatment protocol not applied. Although there’s a ministerial decree that defines violence as a public health problem, the ministry doesn’t apply the treatment protocols for cases of violence. Something similar happens with the problem of abortion. After therapeutic abortion was criminalized, international cooperation supported the creation of an emergency obstetric treatment protocol for extreme cases. And now, whenever this government is criticized by an international body for penalizing abortion, the official discourse always mentions this protocol, claiming that it’s solving the problems posed. Experience, however, is confirming that this isn’t true.

12. Health officials forced to violate their professional ethics. Many of the abortion charges against women have been filed by the heath personnel in hospitals and health centers, which is a grave violation of medical ethics. Those now being charged with terminating their pregnancies include women who experience complications and turn to the public health centers, so we’re seeing health personnel acting as judges, police or priests, but not as health personnel.

It’s very serious that public health officials are being pushed to violate the ethics of their profession and the human rights of their female patients. Gynecologists and obstetricians who previously ran to treat women who needed it now run in the other direction, either to avoid treating them or to accuse them. If a hemorrhaging woman comes in, she’s immediately suspected of attempted abortion, and fearing that they could be accused, the reaction is: “Don’t touch her; don’t do anything; wait until the fetus dies.” And they don’t proceed, even if there’s bleeding, fever or infection.

A gynecologist from the northern Caribbean told us it’s even worse there, because they’re obliged to communicate with Managua before they can treat any woman who comes in with complications resulting from pregnancy. They have no autonomy to decide what to do immediately. Working under suspicion and requiring us to denounce the women are being imposed as custom, which means that a police state pursuing “presumed abortion” is being instituted in emergency situations.

How did we get where we are today?

I want to mention a total contradiction between the revolution’s policy and practice in the eighties and what’s happening today. According to a study of the Managua women’s hospital between 1987 and 1991, the last years of the revolution and first of the Chamorro government, 870 requests for termination of pregnancy were received and the committee in charge approved 509, 17% of which were for economic and social reasons, not medical ones. We mustn’t forget that abortion is less a health problem than one of social class and therefore of social justice. And that’s on top of being a problem of national and political hypocrisy, because women of means can terminate their pregnancies much more easily. They did it before therapeutic abortion was criminalized and they’re going right on doing it now. And everyone knows it. How can we explain that an abortion performed legally in a public health institution in the eighties and would be seriously penalized today, even though we have the same party in power?

As a society, we have to wonder how we’ve gotten to where we are today, with poorer women left to their fate, and doctors under suspicion without being able to exercise their profession freely and autonomously. In those years of free and autonomous medical practice I also observed that the therapeutic abortions approved and performed in the health system represented only 7% of all abortions in the country in that period. That means that therapeutic abortion wasn’t resolving the problem of abortion in general, because the problem isn’t just the risks women face with their pregnancy; even more frequently they don’t want the pregnancy and seek to terminate it for psychological, social, personal and economic reasons. That’s what society needs to understand and respect. I can’t fairly and honestly state that restoring therapeutic abortion will seriously reduce the abortion problem. The only thing that will do that is sex education, men taking responsibility for their sexuality, access to safe contraceptive methods and the total decriminalization of abortion. Achieving and assuming all of that would be difficult, particularly given the Church’s position, and take a long time, but it’s not impossible.

Participatory health care today

The current health care model is presented to us as one of great social participation. And in fact that participation is happening. The problem is that it’s party-biased participation. People’s work to guarantee their community’s health is always voluntary and disinterested, and is an extraordinary contribution. That’s a legacy of the revolution, which couldn’t have produced the health care results it did without such support. Today participation is centralized in and controlled by the CPCs, whose contributions are necessary and very important, as are those of any social organization. The negative part is that in line with governing party orientations, all other local volunteer organizations working in health have been eliminated to privilege the CPCs.

Analyzing different testimonies of what’s happening all over the country, it’s easy conclude that there’s a presidential order for the Health Ministry not to allow women’s organizations any participation and not to provide women’s collectives and women’s centers any public health information. Information that should be public, free, updated and accurate is being denied to us and all arenas of participation have been closed to us, if not closed altogether.

The National Health Council lasted one week with the current government. Health Minister Cuan convened it for the beginning of January 2007 and we’ve never been invited since. The National Anti-Violence Commission, in which the Network of Women against Violence and other specialized organizations were participating, was never again convened. The National Commission against Maternal Mortality was in fact closed during the Alemán government then reopened during the Bolaños government, but included only one member of civil society; it has never even been convened during the current government. The majority of women’s organizations that participated in the Departmental and Municipal Development Councils no longer have access to those arenas. Women used to be able to present demands, proposals and denunciations there, but they have been reduced and virtually no longer function. The current government’s policy, including in its health model, is to totally exclude independent civil society.

HIV-AIDS

Those commissions were based on ministerial resolutions, which don’t have the effect of law. The National AIDS Commission, which is based on a law, is thus the only national commission still functioning and the only sphere in which some civil society organizations are still participating. The fact that there’s a legal mandate and a national project financed by the Global Fund is the only reason we have any information about how the HIV-AIDS epidemic is advancing in the country. Even the information that has been made public and distributed to us isn’t governmental, however; we’ve gathered it through a lot of work, contacts and insistence.

That information allows us to state that AIDS is one of the main problems affecting Nicaragua, and women in particular. Let’s look at some really alarming figures. In 1997, 300 people were on the books as HIV positive. Thirteen years later, in 2010, the number was up to 5,690. The speed with which the epidemic is spreading is very similar to what happened in the African countries.

Furthermore, when the epidemic began in Nicaragua, there were 16 HIV positive men for every woman. Right now there are just under 2 men for every woman. That’s what’s known as the feminization of the epidemic. Over 34% of the people affected in Nicaragua are now women and the epidemic is advancing especially dramatically among the youngest women. According to official reports, the number of girls 14 years old or younger with AIDS has jumped from 2 in 1997 to 87 at the end of 2010. Infected adolescents—both male and female 15- to 19-year-olds—totaled 8 in 1997 and 466 in 2010, of whom 274 are female. With this trend, 2011 will end with females representing 60% of adolescents carrying the virus. While this hasn’t been headline news in the media, it deserves urgent action by the educational and health systems, particularly considering the large proportion of young people in the Nicaraguan population as a whole.

The current government health care model caused contradictions with the disappearance of specific programs such as comprehensive care for women and children, after a decade of work to get it introduced. The HIV-AIDS prevention and treatment program disappeared as well, with both programs reduced to the category of mere “components” of the new model. In the specific case of the HIV-AIDS program, it produced a hecatomb among both people living with the virus and the organizations working on tracking and preparing for it, because the referents and coordination and treatment mechanisms were lost. To this has to be added the ignorance and prejudices related to understanding the characteristics of this epidemic. It has been very difficult to get those who got their medical degrees before the HIV/AIDS virus was discovered and even those who graduated 20 years after it was discovered to understand the dimensions of this illness. Until very recently it wasn’t even part of the students’ curriculum. It’s hard to believe, but universities can also be slow-moving machines that resist change, particularly if we’re talking about issues that generate debate in society.

The problems of HIV-AIDS can’t be adequately addressed without looking at sexual violence. We have to ask how the 87 little girls currently living with the AIDS virus caught it at the end of their first decade of life. We’ve verified that girls and adolescents with the virus are being treated in the health system, but not with the presumption that they were infected through rape. The pregnancy of the majority of teenagers treated in the health system, whether or not they are carriers, isn’t viewed as related to rape. And the same is true when girls of the same age have HIV, even when there’s no other logical explanation for why girls 10-14 years old are carrying it.

Women’s organizations are starting to investigate the origin of HIV in these girls, finding sexual abuse and rape as a repeating parameter, but the health system still isn’t reacting. We have, for example, testimonies from Quezal¬guaque, a very small community in which eight HIV-positive individuals appeared, among them three pregnant girls 10 to 13 years old. The women’s groups went to the health center, where they found out that the doctors (themselves women) who treated those girls hadn’t taken the origin of the HIV into account. They only considered the girls’ pregnancy and treated it as high-risk given the girls’ age and the fact that they were virus carriers, but it never occurred to any of them to ask how they got the virus.

And to situate ourselves even better in the real country, the doctor who treated one of the girls observed: “The thing is she came in with a gentleman and you should have seen how nice he was.” The girl was 12 years old and the “gentleman” 38, but the doctor was happy because she came in accompanied. We’re talking here about a crime that isn’t noticed, recorded or even treated as such. And if women’s collectives weren’t working in ongoing contact with women all over the county, we wouldn’t even know about many of these crimes; they wouldn’t be denounced and no one would be watching out for the life and health of so many women. Nicaragua has 187 affiliates to the Latin American and Caribbean Women’s Health Network, and we’re constantly in action.

Although not without its difficulties, there’s treatment for HIV-AIDS in Nicaragua thanks to resources from the Global Fund program. This prolongs and improves the quality of life of those who take it. But a lot remains to be done to respond to the AIDS challenge. We’re still not taking seriously the African pattern, which I’ve been warning about for the past 15 years. Nicaragua has similar characteristics to those that unleashed the pandemic in Africa and have affected the development of almost all countries on that continent. In 98% of cases, the virus that causes AIDS is transmitted sexually, mainly through heterosexual relations. We aren’t prepared here to prevent this illness, treat it or even respond to its consequences, including the number of HIV-positive boys and girls and/or AIDS orphans.

Alarming holes and enormous challenges

As we can see, the challenges are enormous and the holes notable and alarming. Taking a look at the comprehensive health care of the population, particularly women, we can only conclude that this government or any other government that takes office in Nicaragua is faced with many important pending issues.

Dr. Ana María Pizarro, a founder of SI Mujer, a women’s clinic that celebrated its 20th anniversary this year, is a feminist activist, a GYN-OBS specialist and a researcher.

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