NicaNotes: The Privilege of Free Health Care

By Becca Renk

[Becca Renk has lived and worked in sustainable community development in Nicaragua since 2001 with the Jubilee House Community and its project, the Center for Development in Central America. The JHC-CDCA also works to educate visitors to Nicaragua, including through their hospitality and solidarity cultural center at Casa Benjamin Linder. This article was a first published in English & Spanish here.

Orla spent six nights in the hospital with dengue fever. The bill was C$0.00.

Dengue Fever

We’re settling in to our daughter Orla’s sixth night in the hospital. Visiting hours are over and only ten of the beds in our 32-bed pediatric ward are occupied tonight, down from 20 a few nights ago. The patients – mostly young teens in our room – are tucked in under mosquito nets. Their caregivers – mainly grandmas, aunts and moms – are slouched in chairs or curled around their patients on the beds. A few of us stretch out on unoccupied beds to get some rest before the nurse turns on the lights for the next regular blood pressure and temp check.

Our 14-year-old was admitted to the pediatric ward with dengue fever on July 19th, Revolution Day in Nicaragua. Poor Orla sobbed in disappointment that she wouldn’t be able to celebrate the holiday. After two days of fever, I had taken her to the emergency room in our local Ciudad Sandino Primary Hospital where the blood work they ordered indicated dengue and showed that her platelet count was low enough to be of concern. “She’ll be staying here with us,” the doctor announced. Since then, either my husband Paul or I have been with her in the hospital, tasked with making sure she’s kept hydrated and informed of her progress via blood test results each day.

Dengue fever is a virus transmitted by mosquitoes that propagate in the tropics during the rainy season and it affects 50 million people annually worldwide. Nicaragua works to control outbreaks through regular house-to-house fumigation and eliminating stagnant water – the epidemiology department of the health services visited our house shortly after Orla was hospitalized to kill any mosquitoes or larvae. There is no cure for dengue, just symptom management over its eight-day cycle. The virus attacks the body and can cause leakage in vessel walls, resulting in water loss in the circulatory system and rapid dehydration. Much rarer severe cases can cause internal bleeding and for blood platelets to drop to dangerously low levels. Hemorrhagic dengue is particularly dangerous because patients can go into shock and die before they can get the blood transfusion they need.

Because of this risk, the Nicaraguan Ministry of Health’s policy is to hospitalize anyone with dengue who shows signs of possible complications, including low blood platelets. Thanks to this prudent policy and quality care, Nicaragua is the country with fewer deaths from dengue than any other country in the region – in a normal year, zero deaths. Treatment for the 12 pediatric patients we’ve seen come through our room has been intravenous rehydration fluids and ultrasounds upon being admitted; blood pressure, temperature and blood oxygen level checks every two hours; daily blood tests; and constant monitoring of liquid intake and outflow. Patients with fevers get acetaminophen, patients with suspicious pain are taken for another ultrasound, patients not getting enough fluids are put back on IVs.

Although the staff has been concerned about possible complications for at least four of our patients, including Orla, no one on our ward has been transferred to a larger Managua hospital for emergency transfusions; but the ambulance is standing by outside if its needed. Knowing that gives me incredible peace of mind – at home, how could I possibly have known what Orla’s platelets were doing?

Growing up in the U.S., I never had a close family member admitted to the hospital; in fact, visits to the doctor were rare. As a kid, I remember knowing that if I got sick over the weekend, I’d have to tough it out until Monday when we could see the doctor during office hours. A trip to the emergency room at the hospital – the only after-hours option in my rural county – was too expensive. For the most part, everyone I knew only went to the doctor if they’d been sick for more than a week – their families simply couldn’t afford more frequent care.

By contrast, Nicaraguans seem to go to the doctor all the time. If my neighbor’s kid gets diarrhea, they bring her straight to the emergency room. I used to think this was because people were afraid – in the 1990s and early 2000s, child and infant mortality rates were high in Nicaragua and many kids really did die of preventable diseases. But as child health has improved – infant mortality down by 61% and chronic malnutrition reduced by 66% over the past 15 years – I have finally begun to understand that Nicaraguans take their kids to the hospital because they can.

Back in Idaho where I’m from, Orla’s emergency room visit alone would have cost $2,159 and her six nights in the hospital would have totaled more than $60,000. In the United States, medical debt cripples 41% of all U.S. adults and they scramble to pay outrageous bills: more than a quarter of all fundraisers on crowdfunding sites are for health-related costs.

My mom has been telling her friends in Idaho of our woes. “My granddaughter in Nicaragua has spent the week hospitalized with dengue fever.”

“Oh dear!” Her friends all exclaim (dengue fever does sound awfully dramatic).

“Guess how much their hospital bill is so far?” She asks. They frown and shake their heads, already anticipating that my mom is about to hit them up for donations for a GoFundMe campaign to help cover our bills.

“How much?” they ask.

“Nothing at all!” my mom gleefully reports. “Nicaragua has free universal health care!” Her friends’ shock is palpable. “How,” they ask, “can a poor country like Nicaragua afford to give free health care to its people?”

The answer, of course, is because Nicaragua chooses to make free health care a priority for its people.

Nicaragua’s Trickle-Up Economics

Nighttime in the pediatric ward means little sleep for caregivers. In the morning I wake at three, holding a sleepy Orla upright while the lab tech gets a blood sample from her arm, and then try to coax a bit more fluid down her throat. Crash back into sleep until the nurse comes to collect the papers where we write down our patients’ intake and outflow and do the consequential math: Are more fluids going in than coming out? Next the doctors arrive with the lab results for the day telling us who gets to go home and who has to stay. The hopeful have their bags packed, waiting. The feverish ones stay wrapped in restless sheets, in and out of consciousness, knowing they’ll be here another night.

On our third morning, I start awake at ten minutes to seven and rush to shower and change before my husband Paul arrives– bless him – with strong coffee and the car keys. I kiss Orla goodbye and drive straight from the hospital to interpret for a delegation that is in Nicaragua to celebrate the 43rd Anniversary of the Triumph of the Sandinista Revolution, when the Nicaraguan people overthrew the cruel Somoza dictatorship.

Our first meeting is with Nicaragua’s Finance Minister Iván Acosta. It’s my first time interpreting for him and I soon realize that even with a full-night’s sleep I couldn’t do him justice with my interpretation. He has an obvious grasp of details – quoting figures off the top of his head and speaking for two hours with no notes – but above all else, Minister Acosta is a Big Picture person. He connects the dots for us between policy, action and results, giving perspective to Nicaragua’s entire revolutionary project.

“When we came into office in 2007, following nearly 17 years of neoliberal governments,” he says, “we found the country in chaos.” Minister Acosta explains that the period from 1990 to 2006 when Nicaragua had followed the structural adjustment policies of the World Bank and the International Monetary Fund led to extreme inequality, seriously deteriorated infrastructure, and deep poverty, particularly in Nicaragua’s countryside. “There was no magic solution for any of this. What could we do?” he asks.

Nicaragua’s Sandinista government decided on a blend of social responsibility and economic principles. They began restoring rights – to free health care, free public education and land tenure. But they also worked to find ways to ensure that Nicaragua’s poor majority became active participants in the economy as a way to improve the country’s struggling economy. “We realized that we needed to lower the cost of doing business to be competitive; in order to achieve that, we needed to increase public spending.”

To that end, Nicaragua set about building state-of-the-art roads – now the best in the region – to ensure that products could get to market cheaply and easily; improving access to basic services – now reaching 99% electrical coverage up from just 53% in 2006; ending 12-hour a day rolling blackouts and diversifying to generate clean energy – now 80% of the electricity produced is from renewables; training new teachers and building new schools; and building 24 new hospitals since 2007. Over just ten years, Minister Acosta explains, social spending went from being 10% of overall spending to making up 57% of the country’s budget. But have these policies been effective?

“We have these pro-poor policies, but in many countries only lip service is paid to political policy and it isn’t followed by action,” explains Minister Acosta. “So we do the math – all the various quotients and formulae recommended by international experts – to ensure that our policies are being translated into results: real improvements in the lives of the poor.”

The numbers show that not only has Nicaragua’s economy turned around – sustained GDP growth of 5-10%, historic levels of international investment, and 90% food sovereignty have all been achieved – but also the lives of the country’s poor majority have improved. In 2006, GDP per capita was at $990, but by 2018 it had risen to $2,300. “We don’t have a significant middle class yet,” Minister Acosta cautions, but progress is being made.

Nicaragua’s policy could be described as “trickle up economics” – ensure the poor access to health care, education, land, markets, financing…and the economy will follow.

This is the inversion of “trickle down economics,” the U.S. policy made famous by Ronald Reagan which gives tax breaks and benefits to corporations and the wealthy on the theory that it will stimulate economic growth from the top down.

The problem with the U.S. policy is not only a moral one; in economic terms, it just plain doesn’t work.

Under four decades of “trickle down” policy, income inequality in the U.S. has grown to shocking levels: the wealthiest 0.1% have become rich beyond all comprehension, while most U.S. workers now earn less than half of what they would have been earning if incomes had continued to grow equitably.

In other words, tax breaks and benefits to the richest simply don’t trickle down: US families now work longer hours for less pay while struggling to cover skyrocketing costs. Currently, 22% of the U.S. population can’t access health care due to lack of adequate insurance, 12% experiences hunger and more than half a million people are homeless –many living under the country’s collapsing bridges – one in every five of which are in need of reconstruction.

Given what we know about how stability and quality of life for the majority can improve the overall economy, perhaps instead of asking “How can a poor country like Nicaragua afford to give free health care to its people?” We should really be asking, “How can a wealthy country like the United States afford NOT to?”

Nicaragua’s Community and Family-Based Health Model

“Dengue is treacherous,” the doctor explains to me. “A patient can suddenly experience internal bleeding and become critical in the blink of an eye.”  Orla’s platelets have dropped, and she is in the most crucial day in the virus’ cycle when signs of hemorrhagic dengue can appear. As I sit on the edge of her bed urging her to drink more rehydration fluid, a woman who has been visiting another patient comes over to Orla’s bed carrying a Bible.

“Would you like me to pray for your daughter?” She asks. Orla agrees and the woman asks, “Have you accepted Jesus Christ as your Lord and Savior?” I stop her, not wanting her to get the wrong idea. “We’re not Pentecostals,” I say, “but Orla believes in God.” The woman nods and holds her hands out, palms up. We close our eyes as she begins praying in a soft singsong voice, asking God to look after my baby and heal her. When she finishes, she surprises me by saying, “It doesn’t matter which religion we belong to, it’s all the same God.”

That day, Orla turns a corner – her fever drops and her health begins to improve. I’m grateful to all those responsible – as we say here in Nicaragua, “Thanks to God and the Revolution.” Why the Revolution? Because it has restored Nicaraguans’ rights to free quality health care.

Our entire delegation gets to see the quality of this health care up close. After our talk with Minister Acosta, we visit one of the best-equipped hospitals in the country, the Fernando Vélez Paiz, built new and opened in 2018. Director Dr. Virginia Garcia tells us that patients with non-urgent emergencies wait a maximum of 30 minutes to be seen by ER doctors, and that patients wait a maximum of one month for non-emergency surgeries. “We have four laparoscopic towers performing gall bladder surgeries all day every day,” she says. That surgery would cost $54,000 in my home country, but is free in Nicaragua.

I interpret for Minister of Health Dr. Martha Reyes when she describes to the delegation the advances made in public health over the past 15 years. As she speaks, it is easy for me to chart that path from policy to action to results that Minister Acosta talked about. When she finishes speaking, I thank Dr. Reyes personally for the quality care that Orla is receiving in our hometown public hospital. “Not so long ago,” I tell her, “that wouldn’t have been possible.”

When I moved to Ciudad Sandino twenty years ago, our hospital was literally an empty shell, unable to provide even the most basic services to our community of 180,000. Not only did patients in “public” hospitals have to pay for everything from gloves to sutures, but a dengue patient in Orla’s condition would have actually been safer at home – hospitals were in such appalling conditions with lack of staff, beds and even basic sanitation that it was commonly said that hospitals were where patients went to die.

Thanks to public investment in health infrastructure, increase in personnel, improved and specialized training, and tireless work to involve communities and families in their own health care, Ciudad Sandino now has seven health centers and a hospital which includes outpatient, inpatient and emergency care, a maternal wait home, rehabilitation and physical therapy services, a natural medicine center and a center for cataract surgeries – all services offered free of charge. Comparable improvements have happened all over the country – the change in people’s lives is palpable and the results in overall health are measurable: maternal mortality rates have dropped by 70%, deaths from cervical cancer are down by 25% and average life expectancy has increased.

The Privilege of Free Health Care

On the morning of Orla’s seventh day in the hospital, the doctor tells us that her platelets count is high enough to safely send her home. We leave the hospital with nothing more than her official diagnosis paper, a stamped doctor’s excuse for missing school, and a follow up appointment. We owe no money. There is no itemized bill showing how many nights (6), how many sheets were washed (3), how many cafeteria meals she ate (17), how many full blood tests (10), urine tests (1), ultrasounds (1), IVs (1), or how much oral rehydration fluid she drank (53 liters). Orla and I walk out into the sunshine of a new day, ready to rest and recover, secure in the knowledge that the Nicaraguan government has made a choice to look after us…recognizing that it is a right for all to have access to quality health care, rather than a privilege of the few.

By Nan McCurdy

Calendar for Municipal Elections Announced
The Supreme Electoral Council announced the calendar for the municipal elections to be held next November 6 for mayors, vice mayors and councilpersons. The request for registration of alliances was scheduled for August 19; the presentation and personal registration of candidates is scheduled to take place between September 3 and 6. The final decision of candidates will be made on September 22. The electoral campaign begins on October 12 and concludes on November 1. (Radio La Primerisima, 18 August 2022)

Nicaragua Little League Team Beats Japan in Extra Innings
A Nicaraguan Little League team that won its Latin American Region went to play Little League Baseball World Series at Williamsport, PA. It’s been 51 years since a Nicaraguan team has qualified for these games. The team lost their first game on August 17 to Curacao. But, on August 20 they beat Puerto Rico. Then, on August 22 the Nicaraguan team of 11- and 12-year olds beat Japan in the 11th inning 8 to 7. Then, on August 23 they beat Panama 8 to 1. The team is part of the Catorce de Septiembre Baseball League in the Managua neighborhood of the same name (September 14). Japan and Nicaragua tied for the longest game by innings in Little League World Series History! [Editor’s note: My husband, son and I have been involved with “La Catorce” since 1987; my husband managed and fundraised for them, and my son played in the league.] (Radio La Primerisima, 23 August 2022)

CABEI Increases Credit Line to Central Banks
To support the liquidity management of the Central Banks of the member countries of the Central American Bank for Economic Integration (CABEI), the institution approved the expansion of the Credit Program from US$200 million to US$500 million for each eligible country. This increase will enable the Central Banks to resolve contingencies and strengthen their liquidity position, contribute to maintaining the value of the national currency, as well as to the stability of the national financial system. CABEI Executive President, Dr. Dante Mossi, said, “We are very pleased to support our member countries by increasing the amount of this Central Bank Credit Program, which will support liquidity management and strengthen international monetary reserves. (Radio La Primerisima, 17 August 2022)

CABEI Creates Foreign Direct Investment Fund
The Central American Bank for Economic Integration (CABEI) announced the creation of a Special Foreign Direct Investment Fund of up to US$200 million dollars. Executive President Dante Mossi said that “with the creation of the Fund the role of CABEI as the regional integration bank and bridge to the world is ratified. The goal is to incentivize and facilitate private sector investment in member countries, helping potential investors to overcome barriers established by regulatory agencies of local banks that impede access to financing.” (Nicaragua News, 23 August 2022)

Old OAS Headquarters to Serve as House of National Sovereignty
The Office of the Attorney General granted the House of Sovereignty, named after the late Foreign Minister Father Miguel d’Escoto, to the Center for National Sovereignty Studies. The Casa de la Soberanía Padre Miguel d’Escoto Brockmann will open its doors to academics, intellectuals and students. The premises will be used by the National Autonomous University of Nicaragua, Rubén Darío Campus. The center will operate where the headquarters of the OAS, which was expelled from Nicaragua on April 24 of this year, used to be located. (Radio La Primerisima, 18 August 2022)

Nicaragua Sends Food to Cuba
A Nicaraguan government press release announced that the ship General de Hombres y Mujeres Libres Augusto C. Sandino (General of Free Men and Women Augusto C. Sandino) left Nicaragua on August 18 loaded with food for Cuba. The press release said that the vessel left from Port Arlen Siu, at El Rama, and is expected to arrive at Port Mariel, on August 22nd. (Radio La Primerisima, 18 August 2022)

New Credit Program for Small Producers
The government officially announced the innovative Adelante Program which will provide loans to thousands of small and medium-scale producers, with an initial revolving fund of US$80 million. “It is a highly relevant program for production, development of small businesses, entrepreneurship. It is going to have an impact on the popular economy. It is the synthesis of a continuous effort to bring credit to thousands of small producers who contribute to development,” said the Minister of Finance and Public Credit, Iván Acosta. “These sectors guarantee better distribution of income, access to production, markets and financing,” added Acosta. “Since 2007 we have mobilized millions of dollars that have had an impact on production, trade and consumption with good results. The Adelante Program will have a portfolio of up to US$80 million for agriculture, livestock, forestry, fishing and aquaculture, manufacturing, agribusiness, commerce, hotels and restaurants, transportation and communication, among others. (Informe Pastran, 17 August 2022)

PAHO Director Lauds Health Care Model
The Director of the Latin American Center for Perinatology (maternal-fetal medicine) of the Pan American Health Organization (PAHO), Dr. Suzanne Jacob Serruya, is in Nicaragua to visit health centers and hospitals. On August 19, Dr. Jacob Serruya stated that “the healthcare model in Nicaragua is universal, free and extends throughout the national territory. It is very important to bear in mind that not all countries have a universal and free healthcare model capable of achieving the results that we observe in Nicaragua. These results are only possible when the State recognizes as a principle that health is a human right of the population.” She also noted that “in Nicaragua there are three fundamental components of the healthcare system that deserve recognition not only from PAHO but from other countries as well: The medical brigades that guarantee direct access between the community and the healthcare system even in the most remote places of the country; the Maternal Wait Homes, which have radically reduced maternal and infant mortality rates; and the National Emergency Code that requires that the entire medical hierarchy be notified when there is an emergency involving maternal health. All these strategies converge and create a healthcare system that is comprehensive, family and community oriented, as well as successful, benefitting the entire population.” (Nicaragua News, 22 August 2022)

New Women’s Police Station in Villa El Carmen
On August 17 the Police inaugurated the new Women’s Police Station in Villa El Carmen, Department of Managua. (Informe Pastran, 17 August 2022)

Celebrating the National Literacy Crusade
As part of the celebration of the 42nd Anniversary of the Great National Literacy Crusade, teacher Orlando Pineda received recognition from UNESCO representative Arturo Collado. The activity was attended by brigadistas from the department of Rio San Juan and the Benicio Herrera Brigade, who renewed their commitment to continue defending their victories. Presidential advisor on educational issues Salvador Vanegas gave recognition to the Department of Rio San Juan for its achievements in education. Orlando Pineda presented awards to the department’s literacy teachers. (Radio La Primerisima, 21 August 2022)

Ometepe Island Sewage System Advancing
Representatives of the National Water and Sewage Company (ENACAL) made a site visit to evaluate progress on the construction of the sewage system and wastewater sanitation plant in Altagracia, Ometepe Island, that will benefit 25,000 inhabitants. The project financed by the General Budget with support from the Inter-American Development Bank, costs US$3.7 million and is 75% complete. It will be operational in March 2023. (Nicaragua News, 22 August 2022)

Bishop Alvarez Transferred to a Managua Residence by Police
According to a National Police press release, Rolando José Álvarez, Bishop of the Diocese of Matagalpa, was transferred on August 19 to a residence in Managua by National Police officers. That same morning, Alvarez was visited by his relatives and by Cardinal Leopoldo Brenes with whom he spoke at length. According to the press release, the other persons who were with Alvarez at the bishop’s house in Matagalpa were also transferred to Managua and continue to comply with the procedures of the Judicial Assistance Directorate. The bishop’s house in Matagalpa is open, without any restriction, and under the protection of vicar Monsignor Oscar Escoto. Radio La Primerisima reported that the operation allowed the recovery of normality for the citizens and families of Matagalpa. They had waited with much patience, prudence, and sense of responsibility for a positive communication from the bishop of Matagalpa, which never came. When the destabilizing and provocative activities persisted, made necessary the mentioned operation of public order. (Radio La Primerisima, 19 August 2022)

Former Head of COSEP to Serve Sentence under House Arrest
A court ordered that José Adán Aguerri, former president of the Superior Council of Private Enterprise (COSEP), serve his sentence for treason at home. According to sources from the Aguerri family, the judge accepted the request of the inmate’s lawyers because Aguerri suffers from some health problems that require close and permanent care. Last year, Aguerri was sentenced to 13 years in prison for treason for political actions financed by the US government with the purpose of overthrowing the Nicaraguan government. Aguerri was considered to be one of the main instigators of the terrorist violence that Nicaragua experienced between April and July 2018, but was neither arrested nor tried at that time. However, between 2020 and 2021, together with other accused servants of the U.S. Government, he was involved in preparing another coup attempt that was to be carried out at the end of 2021. His plans were thwarted by the National Police. Aguerri, known as “Chano”, violated Law 1055 by committing “conspiracy to undermine national integrity to the detriment of the State of Nicaragua and society”, according to the sentence issued by the Fifth Criminal District Judge of Managua, Dr. Felix Salmeron Moreno. The prisoner is already in his home to serve the remainder of his sentence under a family regime. (Radio La Primerisima, 18 August 2022)