Today we talk to Dr Hector Real from Nicaragua.
Hector is an Emergency Physician working in critical care at the Hospital Vivian Pellas in Managua.
He is a spokesman for the Nicaraguan Association of Emergency Medicine (ANME) and the ACEP Liaison for Nicaragua.
Hector attended our DevelopingEM 2020 conference in Cartagena and presented on the development of emergency medicine in Nicaragua.
Over the years we have had many fascinating presentations on the struggles colleagues have faced in the development of our specialty, emergency medicine.
The challenges faced by practitioners in Nicaragua is multifactorial and intertwined with a complicated political situation in the country.
This context is something that few of us have to calculate when advancing the expertise of our workplace.
Hector’s presentation analysed the development of EM within this overall context.
You can see Hector’s DEM2020 presentation in Spanish here.
Our follow up interview discusses the challenges that COVID 19 has brought to this setting.
You can see that interview here.
Many of us have only a cursory understanding of Nicaragua and so here is some basic information on the country and its political situation.
Nicaragua is in Central America bordering Honduras to the north and Costa Rica to the South with both a Pacific and Caribbean coast.
Nicaragua has a population of a little over 6 million with 87% of this population being under 55 years of age.
60% of the population are urbanised with 1 million people living in the capital Managua
Life expectancy at birth
(Australia 82.7 / USA 80.30 / Costa Rica 79.20 / Honduras 74.60)
Maternal mortality rate
198 deaths / 100,000 live births
(Australia 6 / USA 19 / Costa Rica 27 / Honduras 65)
Infant mortality rate
16.5 deaths / 1,000 live births
(Australia 3.1 / USA 5.3 / Costa Rica 7.5 / Honduras 14.6)
Current health spending
8.6% of GDP
(Australia 9.2% / USA 17.1% / Costa Rica 7.3% / Honduras 7.9%)
1.01 physicians / 1,000 population
(Australia 3.59 / USA 2.59 / Costa Rica 1.15 / Honduras 0.31)
Hospital bed density
0.9 beds / 1,000 population
(Australia 3.8 / USA 2.9 / Costa Rica 1.1 / Honduras 0.7)
Major infectious diseases
degree of risk- high for food or water borne disease (including bacterial diarrhoea,
Hepatitis A and Typhoid fever)
and vector borne disease (including dengue and malaria)
(Costa Rica- degree of risk- intermediate / Honduras- degree of risk- high)
The Pacific coast of Nicaragua was settled as a Spanish colony from Panama in the early 16th century.
Independence from Spain was declared in 1821 and the country became a fully independent republic in 1838.
The dictatorship of General Zelaya began in 1893 but he was deposed with the help of United States (US) troops in 1909 marking the start of a prolonged period of US involvement in the affairs of the country.
Over the next decade the US established military bases in the country.
Guerrillas led by nationalist Augusto Sandino, after whom the Sandinista movement is named, campaign militarily against the US military presence and were part of the reason for a US withdrawal from the country in 1933.
Sandino was assassinated during peace talks in 1934 on the orders of National Guard commander General Anastasio Somoza Garcia.
General Somoza was elected president not long after in 1937, heralding a 44 yearlong rule by his family.
The Sandinista National Liberation Front (FSLN) is founded in 1961 and identified as a nationalist, socialist and anti-imperialist organisation, whose objective was the seizure of political power through the destruction of the bureaucratic and military apparatus of Somoza’s dictatorship.
In 1978 the assassination of the leader of the opposition parties triggered a general strike and brought together moderates and the FSLN in a united front to oust Somoza.
Violent opposition to governmental manipulation and corruption spread to all classes during 1978 and resulted in a civil war that brought a civil-military coalition, spearheaded by the Sandinista guerrillas, led by Daniel Ortega Saavedra, to power in 1979.
The FSLN government redistributed the vast Somoza family land holdings and promoted radical changes to education and healthcare.
However, it was their anti-imperialist, anti-capitalist and pro Cuban and Bolivarian identity that attracted the ire of the US which systematically commenced a program to remove the FSLN from government.
The Australian journalist John Pilger visited the country at this time and his insightful documentary can be seen here.
This US effort to unseat the FSLN was centred on military support for the anti-Sandinista contra guerrillas, but also involved the mining of Nicaraguan harbours and the enforcement of an economic embargo against the country.
These measures were responsible for enormous hardship and violence within the country and were a contributor to the FSLN losing free and fair elections in 1990 where they relinquished power to the democratically elected opposition coalition.
What followed was a difficult period that saw a gradual reduction in paramilitary violence but also increasing debt and corruption.
After losing further elections in 1996, and 2001, former Sandinista President Daniel Ortega was elected president in 2006, 2011, and most recently in 2016.
This new Sandinista period is a vastly different period to the 1980s with election wins coming at the cost of compromise for many of the FSLN core beliefs.
There have been coalitions with ex contras, rapprochement with the Catholic Church (including support for a ban on abortion by the FSLN), and new accords with the IMF.
Whilst there have also been reintroduction of free education and literacy programs, as well as Zero Hunger programs, and corruption crackdowns, there has also been a reduction in public financial accountability, a freeze on the wages of teachers and health care workers (already the lowest in Central America) and suspect constitutional change allowing Ortega to continue as President beyond the usual two terms previously allowed.
Concerns about an increasing authoritarianism had been growing internally and were recognised by Amnesty International in 2018 when responses to protests against the government outlined Amnesty concerns.
These concerns are more expansively explained here but centre on the reduction of interaction with international agencies scrutinising human rights, an appreciable reduction in the freedoms of expression and assembly, the use of the legal system to prosecute political opponents, increased state sponsored violence and government targeting of journalists, human rights defenders and local NGOs.
In 2019 the FSLN was expelled from the Socialist International due to the same concerns.
In the last 2 years there have been mass protests over wages and social security changes that have morphed into general denunciations of the ruling party and system especially after the very violent responses to the original protests.
The political situation in that period has been a factor behind the nearly 90,000 Nicaraguans who have recently fled the country.
It is into this complicated and multifaceted situation that COVID 19 arrived in March.
Hector’s perspectives on the current situation are fascinating and we remain very grateful for his time and expertise.
If you would like to help in efforts to supply PPE and other equipment then please consider joining with DevelopingEM in donating to the efforts of FNE International.