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Issue 9: Health in Nicaragua

On The Record
Central America After Mitch
Volume 8, Issue 9 – May 27, 1999
Part 1 of 2

In this issue:

• In the News
  • Exclusive: German Deputies to Protest Nicaraguan Aid Scandal at Stockholm Meeting by Donna Vukelich
  
  
• Stockholm Report by Marie Clark
  • Nicaraguan Trade Minister Clashes with NGO Critic Over Comptroller General
  • Central American NGOs Demand that Reconstruction Aid be Tied to Civil Society Participation
  • Indigenous Representatives Complain of NGO "Discrimination"
  • Interamerican Bank Chief Demands Transformation of Society
  
  
• Feature of the Day: Health in Nicaragua
  • Traumatized by the Past and Fearful of the Future
  • Mitch – The Sickening Disaster
  
  

Exclusive: German Deputies to Protest Nicaraguan Aid Scandal at Stockholm Meeting
by Donna Vukelich

Managua, May 25, 1999. A delegation of deputies from the German parliament plans to complain about the misuse of Nicaraguan emergency aid at the doors' meeting in Stockholm, Sweden.

The German deputies visited Nicaragua last week to inspect national reconstruction projects that have received German assistance. According to press reports in Managua, they left disillusioned and alarmed at evidence of wastage and unfulfilled promises.

Meanwhile, there are also reports that emergency food aid donated by Norway has been turning up for sale in one of Managua's busiest markets, prompting an inquiry by the police and the UN World Food Programme (WFP).

On the Record has learned that one of the German deputies, Hans Christian Strobele, plans to take up the matter with his government and the Minister of Foreign Cooperation, and make it an issue at the Stockholm meeting.

One of the sites visited by the German deputies was Posoltega, where a mudslide buried two small communities on the slopes of the Casita volcano. The German deputies were surprised to find that a German-funded project for 684 displaced families had ground to a halt.

Many of the families who survived the mudslide have no land to go back to, and the Aleman administration had promised the refugees and Posoltega Mayor Felicitas Zeledon that the government would provide land to at least some of the refugees. That apparently has not happened.

"(President) Aleman promised last December that the issue of property was going to be resolved, but nothing's happened so far," said legislator Karin Kortmann.

The deputies also met with Sandinista leader Daniel Ortega, but were apparently unsatisfied with that meeting as well. "Everyone from the different parties has said that it's important to aid [Nicaragua], but we don't see how."

Kortman implied that many promises had been made by the Nicaraguan government with one eye on Stockholm, and she wondered what the fate of the refugees will be after Stockholm. "It (the government) knows the language that the donor countries want to hear: transparency, overcoming poverty and sustainable development." But, she said, the delegation left with a rather different impression – that the distribution of aid has been corrupt and secretive.

Meanwhile, it appears as though emergency food aid that was earmarked for hurricane victims is being sold in Nicaragua's sprawling Eastern Market – the busiest in Nicaragua. In addition, there are reports that significant amounts of aid are being held up in Customs or in governmental warehouses, prompting fears that the food could soon expire if not distributed.

One vendor was photographed by a local newspaper holding a box of canned fish donated by Norway. He said he had already sold some 50 boxes, each containing 24 cans of fish. He refused to say where he had acquired the fish, referring only to a "clandestine" warehouse in the market.

This has angered Nicaraguans and local aid officials. CARITAS Director Ronald Bendana Hurtado described the sale of hurricane relief aid as "a crime" and demanded a thorough investigation.

The WFP has announced that it will inspect the eight WFP warehouses, and the process by which foodstuffs leave the warehouses for their intended sites. The WFP issued a communique lamenting that "foodstuffs generously donated by the international community for the poorest in this country have been sidetracked by unscrupulous parties."

On Monday, WFP officials and police officers from the Section of Economic Investigations made a visit to the Eastern Market. But many vendors simply left the market or refused to talk.

"All they do is come and take our products, which we sell just to make a few cents," said one vendor. "But they never really investigate... We buy and sell. Somebody else was stealing from the warehouses, but we end up getting hurt".

Stockholm Report
by Marie Clark

Nicaraguan Trade Minister Clashes with NGO Critic Over Comptroller General

Nicaragua's Minister of Trade, Byron Jerez, has rejected a charge by Nicaraguan NGOs that the government has shown contempt for the principle of transparency by attempting to intimidate the country's Comptroller General Agustin Jarquin.

The exchange came during a panel discussion on transparency in Stockholm Tuesday afternoon. It followed several presentations at the morning inaugural session, including a speech by Nicaragua's President Arnoldo Aleman.

The panelists included Jarquin, whose functions as Comptroller General include investigating allegations of government corruption. As reported in issue 7 of this series, Jarquin earlier this year decided to investigate President Aleman's considerable personal fortune, which has increased ninefold during his presidency.

In retaliation, the Nicaraguan government has launched a furious counterattack against Jarquin (who was imprisoned during the 1980s under the Sandinistas). In particular, President Aleman has accused Jarquin of using illegal methods involving a news reporter in his inquiry.

Intervening during the panel debate, Ricardo Zambrana, from the Nicaraguan human rights organization CRIES, pointed out that when people like Jarquin speak out against corruption in Nicaragua, they are likely to be harassed. This, he said, contrasted with the government's professed support for transparency.

Jerez, the Nicaraguan trade minister, denied that Jarquin had been harassed. In fact, he said, it was the ruling political party that had accused Jarquin, not the government.

The donors established three workshops in all – on transparency, the environment, and decentralization.

Central American NGOs Demand that Reconstruction Aid be Tied to Civil Society Participation

After two days of discussions in Stockholm, representatives from Central American civil society agreed on Monday that reconstruction aid should be linked to their participation in the reconstruction process, and to greater transparency. At least one major donor – Germany – appears sympathetic to the demand.

The NGO position on conditionality was formulated at a series of workshops on Sunday and Monday, and presented to donors on Monday by six NGO representatives. The donors present included the governments of Sweden, the US, Britain, and Germany as well as the World Bank.

Conditionality also features prominently in an NGO declaration, which states: "We share the interest of establishing conditionalities to guarantee an effective process of transformation in Central America, and concrete mechanisms of follow-up with civil society participation." The full text of the NGO declaration will be published in On the Record as soon as it becomes available.

Conditionality continued to be discussed at donor workshops, which took place on Tuesday afternoon after the inauguration. Representatives from the Nicaraguan government and civil society exchanged charges over corruption.

The conditioning of aid is not popular with developing country governments, and the fact that Central American NGOs are recommending that donors withhold aid unless their governments fall into line may create some tension. At the same time, it also shows the determination of civil society to keep up the pressure on their own governments.

According to participants at the Monday discussion, the most forthcoming donor was Germany, whose representative said that Germany has assumed that civil society was already fully integrated into the reconstruction process. If that is not the case, they would have to review German pledges.

The NGO meeting established three workshops on Sunday, covering transparency, participation, and vulnerability.

At the insistence of the Hondurans, a fourth NGO workshop was also established on debt. This ended by calling for the cancellation of all debt servicing (on bilateral and multilateral debt), and stated that the proceeds should be invested in human development and social programs. Each country should create a mixed commission to review plans for writing off debt, it said, and also ensure that the country does not again fall into unsustainable debt. This, too, amounted to conditionality because it linked debt relief to poverty reduction, (as opposed, for example, to the repaying of existing debts).

In another demand, the workshop on debt also called on the International Monetary Fund (IMF) to develop a new code of conduct that would require multilateral lending institutions to share information with civil society.

Encouraged by the way that the governments in Honduras and Nicaragua are coming under greater pressure from independent watchdog ombudsmen and inspectors, another of the four workshops (on transparency) also called for accountability mechanisms to monitor the actions of the civil service, judiciary, and even private management.

This working group also called for an intensive debate on transparency involving donors, civil society, and national, local and municipal governments. The proposals also call for periodic reviews to determine public opinion at each stage, and recommend that the use of public funds be routinely monitored.

Following the NGO discussions, two different papers were issued: the declaration, and a series of recommendations. These were unveiled at a press conference Monday, and formed the basis for the discussion with donors the same day. The meeting was attended by three representatives from the South and three from the North.

Indigenous Representatives Complain of NGO "Discrimination"

Indigenous participants at the NGO discussions have complained of being "discriminated against" and ignored in the NGO discussions in Stockholm.

About ten indigenous persons are present in Stockholm. Although most are representing other NGOs, they are united in demanding that the indigenous perspective should be reflected in the NGO demands.

Jose Luis Escalante, representing the young people of Honduras, was among those who complained during the workshops that indigenous were not being given adequate time to speak, and that their role in reconstruction was not being acknowledged.

Another vocal contribution came from Norman Bent, representing the Comite Costeno, a coalition of 30 groups from the Atlantic coast of Honduras and Nicaragua.

According to participants, the indigenous contribution was not referred to in the initial draft of the NGO declaration, which was put together by six NGO members and presented to donors on Monday. This was rectified, but there are still concerns that indigenous culture might be overlooked and even sacrificed during reconstruction.

In one example, referred to earlier in this series, the Honduran parliament has accepted a revision of the constitution that would permit foreign companies to own land and develop along the Atlantic coast, which is the traditional home of the Garifuna people.

The other question is whether the indigenous contribution will be acknowledged. Indigenous peoples claim a spiritual attachment to the land, which they feel can help protect against ecological destruction. For example, it is traditional in the Mayan culture to apologize to the land before planting seeds.

Throughout the NGO meetings, indigenous representatives have insisted on speaking from a regional, as opposed to a national, perspective. They have also insisted that they were largely ignored by aid donors in the aftermath of Hurricane Mitch.

Reconstruction Should Not Exclude Transformation of Society, Says IDB Chief

The InterAmerican Development Bank (IDB) will commit $3.5 billion to Central America through to the year 2002, and $2.8 billion represents new money, according to Enrique Iglesias, the IDB President; $100 million will be allocated to a new fund for reconstruction.

Speaking at the opening of the consultative group of donors on Tuesday, Iglesias called on donors to realize their pledge to make $6.3 billion available to the region, and described this as a "first step" on the road to reconstruction.

Moreover, he said, "the reconstruction of Central America must not take place at the expense of transformation," and emphasized that "transformation" must include the growth of democracy, and a deepening of peace and modernization.

Iglesias was followed by Cesar Gaviria, the Secretary General of the Organization of American States, and Manuel Marin, the Vice-President of the Commission of European Communities. Each spoke of the need to "transform society" and include civil society in the process.

Like Iglesias, they also called for increased aid and measures on debt. Iglesias acknowledged the importance of debt relief for Nicaragua and Honduras and defended the position of the multilateral banks, which have been harshly criticized by NGOs for piling debt onto the two countries.

He noted that the Paris Club meeting in December had agreed to defer debt repayments over three years, and that the World Bank has established a Central American Emergency Trust Fund to help pay off multilateral debt. Iglesias also expressed the hope that Honduras would become eligible under the World Bank/IMF scheme for highly-indebted poor countries (HIPC). He said that the IDB has earmarked $400 million for Honduras under the HIPC scheme.

The consultative group meeting was inaugurated by Goran Persson, the Prime Minister of Sweden, Kofi Annan, the Secretary General of the United Nations, President Aleman of Nicaragua, and President Flores of Honduras.

Prime Minister Persson stressed the need for trade and better access to export markets, credits at stable terms, debt relief, and investments that will stimulate economic and social development. He said: "Let us go for this vision. That is what will bring welfare and true liberation from poverty and dependence. That is what should be on the top of our agendas."

At the same time, he said, "priorities and the co-ordination of the reconstruction should not be set by donors, but by the people of Central America through their elected representatives and civil society."

UN Secretary-General Kofi Annan noted that the destructiveness of Mitch had been caused by human factors as well as nature. The Secretary General stressed the importance of completing the "unfinished agenda" of the peace process in terms of human rights and reconstruction, and pledged UN help.

Presidents Aleman and Flores, from the two countries worst hit by Mitch, appealed for aid. Both also made a commitment to transparency – even though they have both reacted angrily when challenged at home by watchdog bodies. The donors meeting is due to conclude Thursday with a plenary session, at which pledges will be announced.

Part 2

Feature of the Day: Health in Nicaragua
From the editorial desk

In the following two articles, Donna Vukelich writes about the impact of Mitch on health in Nicaragua. In the first, she accompanies psychologist Martha Cabrera to the scene of the deadly Posoltega mudslide and speaks with some of the survivors about their loss. Secondly, she looks at the weakness of Nicaragua's once-proud health system and explains how this has made Nicaraguans more vulnerable to disease after the hurricane.

Traumatised by the Past and Fearful of the Future

Avelina is one of the few to have survived the Poseltega mudslide which swept down the side of the Casita volcano on October 30, 1999 and buried two villages. The rest of her family was not so fortunate. Her husband, children, and grandchildren all perished. Now Avelina has to cope with the loss. In early May, six months after the disaster, she spoke with On the Record about her fears:

"We are all survivors here and still live with the pain. Time is starting to heal our wounds, but we are still left with the pain. We will never forget. It is difficult to walk or to be in a house. And some days we don't have the will to live. I have to move forward...."

One of Avelina's neighbors lives in Dipilto and lost her house. She is lucky to have her family intact, but (as she told a friend) she cannot stop visiting the place where her house once stood. "I just go there and sit for the longest time. I go without the children. I don't even know if I think while I am there. I just stare at the destruction."

A History of Loss

Recovery from disaster requires building materials and food. But there are other ways of measuring the impact, and putting people back on their feet. One of them is psychological.

Nicaragua knows this only too well. It is a country that has suffered from great loss. To a large extent, that loss is still unresolved, partly because the levels are multiple and complex:

Absent capital. Destroyed by an earthquake in 1972, Managua is for many earthquake survivors a palpable memory. Even today, people speak of the lost city with real longing.

War. Nicaragua has been through two wars – the revolution of1978-79 and the contra attacks of the 1980s. These left a total of 70,000 dead – an overwhelming number for such a small country. To put it in context, think of the size of the United States and how it suffered from the loss of 58,000 US servicemen and women over the course of the Vietnam war.

Politics. For many Nicaraguans, the Sandinista revolution was more than apolitical choice; it was a life project. The electoral loss of 1990 has been hard to absorb, particularly for those who lost family members or friends in the wars.

Unemployment. The 1990s meant massive layoffs. Thousands upon thousands of Nicaraguans lost their jobs and many were forced to leave the country, either to the US or Costa Rica. This silent diaspora has taken a huge toll on Nicaraguan families.
Then came Hurricane Mitch. Because the sense of loss is so overwhelming, many people – particularly young people – find it increasingly hard to look to the future with much hope.

Emotional recovery

Before Mitch, Nicaraguan psychologist Martha Cabrera and a small professional team from the Antonio Valdivieso Ecumenical Center (CAV) were working with women and young people – often not considered direct victims of the war, but absolutely crucial to the future stability of the country.

Their project was just coming to an end, and the team was looking for a way to expand their experiences into a more medium or long-term project to "reconstruct social fabric," when the hurricane hit. They switched to what they call the "emotional and spiritual reconstruction" of Nicaraguans.

The initial focus of hurricane assistance was on housing materials or food. But the CAV team felt that emotional recovery was also of vital importance, and they began working in several areas that had been especially hard hit by the hurricane, including Posoltega and Condega.

Cabrera and the other are critical of the ease with which some groups have slipped into the "easy way out" in plying stricken communities with material goods, but not taking the next step.

"It is absolutely essential that people rediscover their own initiative, their ability to do things for themselves, to resolve their own problems," she says.

The team runs "emotional recovery workshops." These are based on a guide prepared by two psychologists in Colombia who worked with some of the survivors of the 1985 mudslide at Nevado del Ruiz that left 22,000 dead.

The workshops deal first with the pain and loss of the hurricane suffered by Nicaraguans like Avelina, which can be crushing and extended. From there, the workshops move on to the problems of daily life and other unresolved needs. One that comes up time and again is that of domestic violence.

Cabrera says that one of her aims is to work towards a critical understanding of poverty and what each person can do. This, she says, is empowering, rather than victimizing. She says that one clear finding of the workshops is that "loss is a constant in the Nicaraguan population, we found absolutely no one who did not have serious issues to deal with."

Not everyone in Nicaragua understands the need to include psychological help in the overall hurricane relief efforts. In January of this year, while visiting Posoltega, President Aleman declared that "those people still in refugee centers will be sent to cut coffee in the haciendas in Matagalpa and Jinotega." Cutting coffee, he said, would serve as therapy and help heal the psychological scars of the victims. Posoltega Mayor Felicitas Zeledon was horrified by the idea, noting that most people in the area are still in shock.

The Trauma of Poverty

On May 20, nearly seven months after the mudslide buried two small communities on the slopes of the Casita volcano, Martha Cabrera and her team accompanied the Posoltega survivors as they buried some of the Posoltega victims in a mass grave.

Although there have been several rains, enough to cause concern about further landslides, that day was brutally hot and dusty. In the distance was that compelling ribbon of mud – narrow at the top, splitting into two and widening further down the slope. It looked almost innocuous from a distance. But it will mark lives in the region for years to come.

Cabrera is convinced that the grief in Posoltega is deeper precisely because it is unresolved, in that so few people were actually able to claim and bury bodies, with all the attendant rituals. One man at the May 20 ceremony had gone to Costa Rica over a year ago in an attempt to support his family. He managed to send money back every month, but is the only one in his extended family who is alive today. He is now wracked by survivor's guilt.

In addition, says Cabrera, the some 2,000 survivors are affected "not only by the loss of their loved ones, but also the fact that they have now been living six months in inhumane conditions."

Looking back on the last six months of work, Cabrera says: "It's been a tough process, but it's also given us a lot of hope. We try to take it all in, and learn every day as we do so.

"I don't really feel like a traditional psychologist in this work, because I can't only deal with the emotional pain they're going through. Once we deal with that, what's next? What about housing? What about jobs? What about the poverty that is engulfing this country? We have to have a new vision as professionals, and try and deal with life as people experience it. [There are] so many things, very much connected to each other."

• Thanks to Lisa Arnolds for assistance on this article. For further information on the workshops discussed here, contact the Antonio Valdivieso Center or the Women's Network Against Violence.

Mitch – The Sickening Disaster

When tornadoes or hurricanes sweep through areas of the United States, it is not automatically assumed that epidemics or serious health problems will follow. But when Hurricane Mitch swept through Nicaragua, it was almost inevitable that the population in the affected areas would be exposed to health risks. This was because the country's fragile health system was stretched to breaking point even before the hurricane hit.

According to pre-hurricane United Nations Development Program (UNDP) statistics, 13 percent of Nicaraguans do not survive to the age of 40; 12 percent are seriously malnourished; 47 percent do not have access to clean running water; 35 percent are illiterate; and 44 percent are surviving on less than one US dollar a day.

Infant mortality in Nicaragua is reported at 71 deaths per 1,000 live births. It may well be higher because of under-reporting: a high number of births take place at home, particularly in the countryside. In addition, registering a child means a trip to the nearest municipality, and costs money. Thus, many children are born and die without ever showing up in official statistics.

Most are killed by diseases like respiratory problems and gastrointestinal illnesses, which could be easily prevented by the provision of clean water. Maternal mortality is among the highest in the region and cervical-uterine cancer is a growing problem as well.

Why is all this happening? Partly because per capita spending on health care has decreased by more than 60 percent since the late 1980s, and because deregulation of Nicaragua's pharmaceutical market has led to soaring prices for nearly every kind of medication.

Mitch inflicted more damage on this battered health care system: 90 healthcare centers were destroyed and 417 health posts damaged. In addition, many people suddenly found themselves without clean drinking water. Food supplies were (and continue to be) insufficient in many of the most affected areas.

As victims were moved into temporary or semi-permanent shelters following Mitch, health officials and volunteer workers began to report numerous cases of conjunctivitis, diarrhea, respiratory infections, and a number of skin infections and funguses. These were caused by spending prolonged periods of time in mud or water.

But the woeful state of the country's health care system was such that it was quickly overwhelmed. Many Nicaraguan doctors and health care workers were mobilized to work in the affected areas, but scores of foreign medical brigades were also needed. They came from such countries as Spain, Mexico, Panama, and the United States, and included several small volunteer brigades.

Cuba's doctors prove indispensable

Cuba provided some interesting and politically sensitive assistance. The day after the Posoltega mudslide, the Cuban government offered to send medical supplies and medical teams.

Cuba has a history of helping Nicaragua after disasters. It set up a field hospital in Managua after the devastating December 1972 earthquake, and sent enormous amounts of aid after Hurricane Joan in 1988. On this occasion, however, Nicaragua's President Arnoldo Aleman accepted the supplies, but turned down the teams, slighting the Cubans by insinuating that they wanted to come to Nicaragua only to use up the country's resources. Nonetheless, Cuba sent the medicines to Nicaragua, and medical teams to other parts of Central America.

Then Nicaragua was hit by an outbreak of leptospirosis, a deadly disease spread by rat urine. Leptospirosis mirrors the symptoms of dengue fever which is endemic to Nicaragua, and this makes early detection (key to proper treatment) particularly difficult. The first recorded cases in Nicaragua had occurred in the early 1990s in Achuapa. (Ironically, they had been controlled with the assistance of Cuban medical teams.)

The rat population in Nicaragua multiplied rapidly after Mitch, and cases of leptospirosis were reported in El Viejo, Chinandega, and Esteli. By mid-November, four people were dead in Esteli and more than 70 suspected cases had been reported in Chinandega alone – three resulting in death.

Shortly afterwards, when the death toll had risen to 15, the Ministry of Health was forced to appeal to Cuba for medical assistance. A brigade of Cuban doctors arrived in the country, armed with biorat poison. They also brought food, water, and supplies for their own use – a pointed response to Aleman's initial comments that the Cubans would have been more of a burden. Many Nicaraguans are convinced that leptospirosis would never have been a problem if the Cubans had been permitted to come earlier on.

Cuba currently has medical teams working along the Coco River in the northern Atlantic Coast region, in Posoltega, Esteli and San Juan de Limay. In addition, some 300 Nicaraguans will be offered full medical scholarships to study in Cuba on the condition that they practice medicine for at least two years in the Nicaraguan countryside upon their return.

All of the medical brigades coming to Nicaragua note that while the immediate health emergency may be over, they also have to treat the effect of grinding everyday poverty and underdevelopment. Until the most basic needs of clean water, livable housing and proper nutrition are met, the vast majority of Nicaragua's rural population will continue to live in conditions of crisis.

In the next issue: Landmines in Nicaragua

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