NicaNotes: From Headache to COVID Test: My Journey through the Nicaraguan Public Health System

By Becca Mohally-Renk

(Becca Mohally-Renk works with the Center for Development in Central America in Ciudad Sandino.)

The Hospitalito in Ciudad Sandino, taken before the pandemic. Photos from CDCA.

In early October I got a headache that wouldn’t go away…and it put me right inside the debate over Nicaragua’s response to COVID-19. Despite being the poorest country in the region, since the coronavirus pandemic hit Central America earlier this year, Nicaragua has consistently had fewer cases, fewer deaths and more successful recoveries per capita than any other country in the isthmus. Our organization, the Center for Development in Central America runs a health clinic in Ciudad Sandino, just outside Managua. Since July we’ve been hearing criticisms that the government is hiding a second wave, but that hasn’t come about yet – folks have been cautiously going about their business, gradually returning to normal life, albeit with masks and hygiene protocols. Still, when I got a headache that wouldn’t go away followed by body aches and fatigue, I was cautious.

Because I work with folks over 60 who have compromised immune systems and chronic conditions, I stayed holed up at home. Uncertain what to do when I still wasn’t feeling 100% a few days later, I called the free 24-hour COVID hotline that the Nicaraguan Health Ministry (MINSA) set up in April. The operator answered on the first ring, no waiting, no hold music. I explained that I wanted to know whether or not I should be quarantining. My husband and I had been sending our 8th and 9th grade daughters to their public school where masks are required, but we were unsure whether or not to keep sending them since I wasn’t feeling well. The operator asked for my name, address, ID number, age, and asked if I had any pre-existing conditions. He went through a list of symptoms with me, then he told me a doctor would give me a callback. Less than five minutes later, a second operator called to re-check symptoms with me. Another three minutes went by, then I got a call back from the doctor. She went through my symptoms and medical history with me and advised me that while I probably didn’t have COVID, I should go in to see a doctor about the headaches.

Two days later when my headaches weren’t better, I’d had a blood test showing a virus so I called the hotline again. As soon as the operator picked up and introduced herself she said, “Is this doña Rebecca? You called us a few days ago because you’d been having headaches? How are you feeling now?” They had my number registered and all my information popped right up. The operator went through the symptom checklist with me again and when I told her about the test result she said, “You should really go in to your health center, your assigned center is the Hospitalito in Ciudad Sandino in front of the police station. I always see that it’s empty there, the attention should be fast. It’s best if you go in.” When I got a call back from the doctor, I asked if they would test me for COVID and he told me that would be up to the doctor who examined me; if I wanted to ensure I got the test, I could go to the central MINSA offices in Managua and pay $150 to get tested.

I found myself hesitating to go in. When the first coronavirus cases were reported in Nicaragua, opposition groups flooded social media with stories of hospital systems collapsing, overrun with the virus. On WhatsApp I was forwarded lists of “recommended” medicines to buy in case my family members got sick. Near my office the lines at the pharmacies to buy these medicines went around the corner and my coworkers were charged $6 for an aspirin tablet. Meanwhile the Health Ministry used TV and radio jingles to counteract bad information: as soon as you get sick, go to your local health center to have a doctor examine you and give you medicine appropriate for your medical history and current condition, all free of charge.

Unfortunately, in May and June many people were too afraid to go to the doctor and the opposition’s lies were paid for in lives lost. Recently I talked with a friend whose family story shows the consequences of misinformation: her sister listened to government advice and as soon as she had a persistent headache she went right in to the public clinic. She was given medicine and quarantined at home where she recovered from a mild case. A second, wealthier sister refused to go to a doctor. When she got sicker she paid a small fortune at a private hospital, but kept getting worse. Finally she went to the public hospital where she was hospitalized and eventually recovered from a severe case of coronavirus. The third family member, a cousin, was too scared to seek care in the public system and too poor to go to the private hospital. He waited at home until he could no longer breathe, and by the time he went to the public hospital he died before they could intubate him.

It was with those lessons in mind that I decided to go to the public hospital in Ciudad Sandino, reasoning I’d rather overreact to a headache than be hospitalized later. I went after 5 o’clock, thinking it would be quieter with the normal outpatient services closed. I was shown to a separate building where I sat outside on a bench to wait with one other patient. After a short wait a nurse checked my temperature, blood pressure and blood oxygen levels. I was then ushered into the exam room where the doctor sat behind a desk 12 feet away. She asked questions about my symptoms and looked at my lab results. The doctor then examined me, looking in my throat, listening to my lungs. She told me that based on clinical exam and my lab tests, they couldn’t conclusively say whether I had COVID or not, so she gave me an appointment to get a COVID test the following morning. The doctor explained that because the COVID tests require full PPE and room disinfection, they schedule all the patients at one time to simplify the process. She told me that they do six COVID tests per day at the hospital, and that at 6:30 PM I was only the sixth possible case that day that had warranted a test.

The following day I went back to get my test at 8 AM. Three other patients and I waited two hours for the final two patients scheduled – they never showed up. As I was waiting, I thought about how the best epidemiological plan still has to contend with human nature. For example, the two missing patients had a chance to find out – for free! – if they had coronavirus. Maybe they didn’t want to wait, maybe they were scared, maybe they felt better, but whatever the reason, they didn’t show up. As anyone who works in public health around the world can attest, getting people to change habits is difficult. Providing them with access services, however, is something that the current government has been able to do – and for patients in Ciudad Sandino over the past 14 years, it has changed their lives dramatically.

It’s called the “Little Hospital” because the Hospitalito – which serves a city of 180,000 – was technically a health center until just a few years ago. During 16 years of neoliberal governments, one building was designated for outpatient services and the second building sat empty. Our CDCA health clinic employed doctors who also worked at the Hospitalito, and they told us that they didn’t even have gloves to examine patients. Every time I went down the street outside the Hospitalito I was stopped by people begging for taxi fare to take their family members into a hospital seven miles away in Managua because there was nothing to be done for them at the Hospitalito and there was no ambulance.

Now the Hospitalito has full emergency services and two ambulances. When I walked through the gate at 8 AM there were over 100 patients waiting to be seen by Operation Miracle, where Cuban-trained ophthalmologists perform more than 10,000 cataract removal surgeries for free annually. I watched families coming in with food and packages for mothers who had recently given birth there – before, women had to go all the way into Managua to give birth; I drove one neighbor who had patiently waited until morning to ask me for a ride and then gave birth just 10 minutes after I dropped her off! Now expectant mothers don’t have to travel while in labor – they were there watching the morning bustle from the porch of the maternity waiting home where they wait out the last two weeks of their pregnancy, resting and being closely monitored by doctors. I walked through the full outpatient areas – gynecology, psychology, pediatrics, and general medicine. As I stood waiting, I could see the constantly moving lines at the pharmacy to pick up free meds and at the laboratory to get free exams. I watched one of the two ambulances get loaded up with tables, chairs, vaccines and medical students and head out to a community health fair. A mototaxi with the MINSA logo emblazoned on it came and went constantly, taking personnel and provisions to the six related health centers open daily and even two rural health centers that are staffed once a week.

And in the midst of all that bustle sat four lonely patients with possible COVID. At 10 AM when I was called in, the doctor in full PPE had me sit down and explained the procedure to me. He stuck a probe way up each of my nostrils and explained that I would be called within two days if my test was positive. If my test was negative, I wouldn’t get a call. I asked if they’d only been doing six tests a day throughout the pandemic. He said no, they had been doing more, but now many days they don’t even have six patients to test, so they randomly test staff to fill their quota. He told me that patients who are clinically shown to have COVID with physical exam are treated as COVID cases, given medicine and counted in the official coronavirus numbers reported weekly at a national level. Anyone who cannot be clinically shown to have COVID is scheduled for the test, and those patients who test positive are also reported in the weekly COVID numbers.

As I went home to await results, I realized that while we don’t yet know why Nicaragua’s COVID numbers are so much lower than their neighbors – maybe experts will be able to determine whether policies such as not ordering a lockdown played a part in its lower caseload – it is clear that Nicaragua’s public health policy set the country up to successfully battle a pandemic by creating a healthier country overall. Although my COVID test was negative this time, I found myself relieved to know that if I feel sick again, I can count on quality care from MINSA.

 

Briefs

By Nan McCurdy

Foreign Agents Law Passed in National Assembly
On Oct. 15 the National Assembly approved the Foreign Agents Regulation Law that creates a legal regulatory framework for natural or legal persons representing foreign governments, institutions or agencies. National Assembly Deputy Wálmaro Gutiérrez said all nations have the fundamental right to guarantee their sovereignty; the law is merely to prevent foreign interference. Organizations that have a legal mission have no reason to fear. Many other countries have much stronger laws than this one, including Costa Rica, El Salvador, and the United States. Deputy Filiberto Rodriguez said “We believe this law will guarantee the rights of Nicaraguans to peace and tranquility. This is not a criminal law; this is an administrative law.” Deputy Carlos Emilio López stated “This law does not affect the non-profit associations that promote social, economic, and community development, the improvement of the living conditions of children, women, youth, native peoples and Afro-descendants, persons with disabilities, and other sectors. This law does not limit, inhibit, or restrict the actions of organizations that are focused on promoting development and human rights.” The Assembly approved a reform proposed by the President exempting intergovernmental humanitarian organizations, diplomatic missions, international cooperation agencies and duly accredited staff of these entities, international media and their correspondents, legal persons of religious character duly registered, foreign owned factories, and persons who establish commercial relations under treaties or agreements. Radio La Primerisima, 15 Oct. 2020

Over Half of 2021 Budget for Social Spending
The government will allocate 57.6% of the General Budget for social spending in 2021, reported Dr. Ivan Acosta, head of the Finance Ministry on October 15. Twenty-one percent will go for health care and 24.6% to education. Subsidies for transportation, electricity and water for vulnerable sectors will continue. Nearly US$30 billion will be invested in water, sanitation, electricity, and roads, among other things. Remittances continue to grow by 8% annually.” Radio La Primerisima, 15 Oct. 2020

Nicaragua Records 17% Annual Export Growth
As of the 30th September, Nicaragua recorded a 17% year-on-year increase in the value of its exports, reaching US$2 billion for the first 9 months of the year, reported the Export Processing Center (CETREX), and recognized by the Economic Commission for Latin America (ECLAC) and the Secretariat for the Economic Integration of Central America (SIECA). Informe Pastran, 15 Oct. 2020

Nicaragua hosts FAO Conference
The Thirty-sixth FAO Regional Virtual Conference, chaired by Nicaragua, was inaugurated on Oct.19 from Managua. This event is relevant for Latin America and the Caribbean, in recognition of Nicaragua’s great advances in agricultural production and food security. At the opening of the conference, FAO’s Deputy Representative for Latin America, Eve Crowley, recalled that in 1982 Nicaragua also presided over this conference as it does now and stressed that “Nicaragua has been a fundamental ally in the organization and has shown enormous leadership and protagonism for which we are very grateful.” Fifty-one ministers of state, all regional ministers of agriculture, 40 vice-ministers and 364 other delegates are participating, including the Prime Minister of Haiti, the Vice-Presidents of Ecuador and El Salvador. Since the first session of the FAO Conference of the Americas in Quito, Ecuador in 1949, there have never been so many participants. Foreign Minister Denis Moncada, stressed that Nicaragua has adopted all the measures and protocols to face the COVID-19 pandemic but it did not confine the population, nor paralyze the economy; it stopped neither agricultural production nor public education. He noted the national day of vaccination against influenza that helped reduce the incidence of respiratory cases. He also emphasized the increase in exports and the economic and social transformation favoring the poor majorities where the people are the protagonists. He said that chronic child malnutrition has been reduced by 46% among children under five and 66% among children aged 6 to 14; maternal mortality has been reduced by 67.8% and child mortality by 60.7%. Nicaragua has reduced the gender gap, going from 90th place to 5th place. Drinking water has increased from 65 to 91.8%; electrical coverage exceeds 98%. He added that great improvements have been made in free health and education and, for the first time in history, the Caribbean and the Pacific have been joined by new roads, the best roads in Central America according to the World Economic Forum. Informe Pastran, 19 Oct. 2020

7,000 Scholarships Offered for 2021
On January 16 and 17 of next year, 7,020 university scholarships will be offered by the government at a fair to be held at the Olof Palme Center in Managua. High school graduates will be able to opt for 42 courses of study, including Economic Sciences, Medicine, Civil Engineering, Architecture, Systems Engineering, Computer Science and Communication Sciences. The requirements are only an ID Card photocopy, a certificate of grades for the last two years of High school, a photocopy of the high school diploma showing academic performance of at least 80 percent and a letter addressed to President Daniel Ortega. Master’s degree scholarships will be offered in Education, Educational Management, Criminal and Procedural Law, Psychology, Business Science, Forensics and Criminal Law, among others. Radio La Primerisima, 21 Oct. 2020

M&R Survey Shows Strong Government Support
78.3% of the population approve the management of the Sandinista Government led by President Daniel Ortega and Vice President Rosario Murillo, according to a survey by M&R consultants released Oct. 20. President Ortega enjoys the approval of 66.1% of Nicaraguans. 61.5% of citizens consider Nicaragua’s five-year future to be one of stability, security and economic progress. 82.1% consider that the country has made progress in relation to six years ago. 81.7% agree that the country should return to the course it was on before April 18, 2018, and 93.8% are convinced that the opposition roadblocks of 2018 caused economic damage. 57.9% expressed their approval of the Sandinista National Liberation Front (FSLN) and 8.5% expressed support for the opposition. 67.6% consider MINSA’s approach to the Covid-19 crisis to be good, and 18.6% consider it to be bad. 79.5% are satisfied with public education services, 79% with the roads, 77.5% with public transportation; 73.2% with health services and 75.6% with drinking water service. See more here: https://radiolaprimerisima.com/noticias-generales/destacado/casi-79-por-ciento-de-nicaraguenses-aprueba-gestion-del-presidente-daniel/ Radio La Primerisima, 20 Oct. 2020

Mega Wastewater Project in Bluefields
Nicaragua together with the cooperation of the Central American Bank for Economic Integration (CABEI) is beginning the mega wastewater project in Bluefields. This project will invest US$34 million over 24 months, generating 1,200 jobs. The drinking water project in Bluefields is near completion and will improve the lives of about 12,700 families. Informe Pastran, 19 Oct. 2020

Women’s Police Stations Relaunched
The National Police relaunch the Women’s Police Station in Condega, Estelí to provide security for 16,000 women and next week the station in La Trinidad, Estelí, will be opened. On Oct. 23 the new Citizen Security Unit will be inaugurated in Muelle de los Bueyes, South Caribbean and next week another one in Nandasmo, Masaya. Informe Pastran, 20 Oct. 2020

Youth Graduate from National Hotel School
120 young people will graduate this year from technical careers at the National School of Hotel Management and Tourism. Careers include General Technician in Cooking and Gastronomy, General Technician in Pastry and Bakery, General Technician in Bar, Restaurant and Cafeteria Service. Radio La Primerisima, 15 Oct. 2020

Weekly Covid Report
The Health Ministry Covid Report for the week of Oct. 13 to 19 found 65 new reported cases of Covid-19, 72 people recuperated and 1 death. Numbers have decreased consistently since May. In total since March 18, there have been 4,362 reported cases, 4,126 reported people who have recuperated and 155 deaths. Juventud Presidente, 20 Oct. 2020

Ten Thousand Finish Prison Term at Home
The Head of the Ministry of Government said that, in compliance with the promotion of family unity and social reinsertion, between October 2019 to September 2020, 10,304 people have benefitted from finishing their prison sentence at home with their family. Informe Pastran, 20 Oct. 2020