A Glimpse at Healthcare in Nicaragua

One thing John and I say about our life here in Nicaragua is that we never know what each day will bring. Last Friday this point was driven home yet again.  I had been participating in a workshop for community health volunteers with a group of boisterous, funny, irreverent, and committed women.  Several women brought their children to the training because they had no other childcare option, which raised the ambient noise level to a point where I could often hear nothing.  Then a magical moment happened and we were all standing in a circle in silence (even the children were still), many of us had tears in our eyes, while one woman sang her song of gratitude.  Here’s the background:

In Nicaragua health care is a right and it is free.  There are for profit private practices and facilities for wealthier or insured people as well as government supported health centers and hospitals, which cost nothing.  As a Peace Corps volunteer, I work in the public system and find it very refreshing to be in a healthcare facility with no finances attached (no copays, no outstanding balances, no trouble for the personnel due to poor collections, etc.).  People arrive in the morning, state the reason for their visit, wait their turn, have their consultation, fill prescriptions if needed at the in-house pharmacy (also free) and leave.  Of course it is not a perfect system.  The waits are sometimes long (this is true in many aspects of Nicaraguan life so the waiting does not cause the same irritation it does to North Americans, it is simply part of life), if extensive testing is needed it might not be covered by the government budget and may be too expensive so it does not get done, and the pharmacies often lack the needed medications so patients need to go to private pharmacies which they cannot afford.  Nevertheless, there are many aspects to the healthcare system here which I love, my favorite being the network of community health volunteers. 

Among the community health volunteers are midwives, brigadistas, and recently a new program training community health volunteers to dispense prescribed birth control in their communities.  Sadly, the midwives are doing very few births in Nicaragua.  Due to the high infant and maternal mortality rate, a national movement to institutionalize births was initiated about 20-30 years ago.  Most births now take place in hospitals or health centers with a doctor in attendance.  Initially midwives were invited to do the births in the institutions and/or instruct the doctors and nurses on various ways to support women in labor and positions for birth but their presence has been slowly phased out.  In the hospital in Chinandega, there is no midwifery involvement and the women receive little support in labor.  Midwives are trained to support pregnant women in their communities, refer them to the health centers for routine prenatal care, teach about nutrition and breastfeeding and to be aware of danger signs in pregnancy, childbirth, postpartum and with the newborn for immediate transfer to the nearest facility.  They are no longer being trained to perform births. 

The brigadistas are trained to provide basic health support in their communities.  I have been participating in a 12-day brigadista training and the curriculum includes the basic philosophy of community health, the importance of a healthy environment, care of children, care of women, care of adults and basic first aid.  There are 25 women and one man in the training, most of whom have been brigadistas in their communities for several years and are participating for their required review.  I decided to attend this training so I could learn more about the role of the brigadistas in the Nicaraguan healthcare system.

There were 3 problems for me at this training.  1. We were in a room with poor acoustics so when people spoke it was hard for me to hear. 2. There were children (7 one day) playing, whining, and making general kid noise, which added to my inability to hear.  3. It is not customary for Nicaraguans to give undivided attention to the speaker so while one person is speaking, there may be many side conversations going on, phones ringing, and children being disciplined which often made it look to me like the main speaker was simply moving his or her lips. 4. My own level of Spanish is not advanced enough to understand when people are speaking fast and in the vernacular.  With this combination of factors, I often could hear nothing and had no idea what was going on.  Nevertheless, I got the gist of things and occasionally added my perspective to the conversation.  Strangely enough, when I spoke, everyone listened.  (Gringo power!)

Kids present at the training

One particularly verbal participant

Facilitator on his cell phone

Last Thursday and Friday the topic was the care of women (body parts, menstruation, menopause, screening for cervical and breast cancer, pregnancy, labor, delivery, postpartum, birth control, etc.).  The focus was to inform the participants of how the system works and how to identify danger signs for referrals to their local health center.  I had been participating quite a bit on Thursday and when I was leaving, I asked the leader what was on the agenda for Friday.  He said family violence so I offered to bring my poster of the circle of violence to share with the group.  He said, “Great, why don’t you do the whole presentation,” and I agreed. 

I immediately called my friend and fellow Peace Corps volunteer Jules who had recently led a very successful discussion on domestic violence with a group of HIV positive women.  She walked me through her presentation and told me about some Peace Corps resources available to me.  I spent several hours looking through the resources and organizing my presentation.  I had never done a formal presentation on domestic violence so I was feeling a bit nervous. 

It went surprisingly well. I did some parts of the presentation and the Nicaraguan facilitators did others.  I was pleased with two activities I led.  The first was having each person say one word that came to mind when they hear the word violence.  Each word was written on a large paper for everyone to see.  Next we repeated the activity sharing one word that came to mind when we think of a world without violence. We looked at the two lists and all agreed that we live in the world with violence but yearn for the other list to be our global reality.

For our finally activity we stood in a circle and one of the facilitators read a list I had given her.  The first part described various acts of violence and if anyone in the circle had been a victim of one of those acts, they took a step forward, stayed there for a moment and then returned to the circle while the next act of violence was read.  The second part read the same list but it referred to acts of violence that we ourselves have committed.  In the end there was a reflection about the need to address our own violent behavior and find healthy alternatives to conflict as we take on the issue of domestic violence.  We asked for reflections from the group and one woman shared her story of being a victim of domestic violence.  When she started to cry, everyone became silent giving her complete attention.  As she finished her story, the male nurse who was one of the facilitators, opened his arms and gave her a big hug.  We all followed his lead and when everyone had given her a hug, she sang a beautiful song of gratitude and strength.  The room was silent. 

The power of asking the question and giving space to be heard is sometimes overwhelming.