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




See also this related article : Nicaragua Battles COVID-19 and a Disinformation Campaign

photo credit: CDCA. 


By Becca Mohally-Renk

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

This article was originally posted by Alliance for Global Justice:

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.