"Fear always exists. There is always fear of divulging any information... there is always the feeling that speaking is a sin," says a health worker from a public hospital in Nicaragua, who agreed to talk to CONFIDENCIAL about the real situation of the coronavirus pandemic, with the condition of omitting his real identity for fear of reprisals. He is not the only one who is afraid.
In Nicaragua, fear is the common denominator in public health units, where doctors have no voice because those who have spoken out have been fired. It is the same fear that exists in various areas of the country to express an opinion against the policies and guidelines of a government that tries to impose its truth, putting the lives of many at risk. Even in a pandemic.
"The other day I received a call from a doctor, from one of the public hospitals, and he told me that he was worried because they were not giving him the vaccine, even though he was a first responder and in contact with intensive care patients. He said it with a fear that makes my heart sink because they cannot speak or complain for fear of being fired, because there is harassment, there are repressive measures if they speak out. Right now I can't even say which hospital it is, because it would put him at risk," says Dr. Anely Perez, secretary of the Nicaraguan Medical Unit.
In the pandemic, fear and state silence prevent us from knowing the real impact of covid-19. Even within the health personnel themselves. The Ministry of Health (Minsa) has never publicly acknowledged how many health personnel have been infected or died in the past 14 months of the pandemic.
The most accurate data is gathered by the Citizen Observatory COVID-19. According to its latest report, as of May 12, the figure already stands at 1010 infections, which includes more than 550 doctors and more than 160 nurses. Of these, 125 have died. And those numbers continue to grow. In the last month, which has seen a sharp rise in infections, three doctors and two nurses have died. And at least three more doctors nationwide are known to be in Intensive Care Units (ICU).
Facing the outbreak without vaccines
Nicaragua began vaccinating healthcare workers against covid-19 almost a month after the deadline set by the World Health Organization (WHO), which called on all nations to immunize healthcare workers in the first 100 days of 2021.
Vaccination began on May 3, two months after the first doses began to be applied in the country, and lasted only four days. During this period, Minsa applied the first dose of the Covishield vaccine to front-line staff, ambulance headquarters and international health offices. However, there were many doctors who were not included.
"Everything went through a selective list of each public and private hospital that was cut and then approved by the Ministry of Health (Minsa). So few of us who were the 'privileged' ones," wrote Dr. Carlos Quant, who is one of the doctors fired in 2020 for demanding personal protective equipment for the guild.
The application of these doses arose in parallel to the increase in covid infections experienced after the Easter vacations, which included an increase in cases within the health guild. According to data from the Citizen Observatory there were 112 new suspected cases and five deaths between April 20 and May 12. This figure has not been seen since June 2020 and reflects the level of exposure of Nicaraguan healthcare workers.
"There is something that worries me and it’s contradictory. The thing is, having the possibility of vaccinating personnel before the second wave that we are having - because it could have been possible to vaccinate the health personnel with at least one dose - it was not done. In spite of the fact that we asked for it (...) And it’s not until now, when we are in a resurgence, that they are vaccinating the first line", claims Dr. Perez.
She also points out that the vaccination should have included more than only front-line personnel, since last year there were doctors from other specialties, such as Gynecology, who were infected and died from covid-19.
"The risk of getting sick and dying from covid-19 for Healthcare workers is about seven times higher compared to other non-essential workers. Only hemodialysis patients are at higher risk. That tells you that health workers should have been prioritized in second place and we don't know why that wasn't done," says Dr. Jorge Miranda, a pulmonologist who has treated covid-19 patients in private hospitals in the capital.
Having infected health personnel increases the risk of death of the patients, reiterates the doctor, because "the collapse of the health system occurs not only due to the lack of beds, but also due to the lack of qualified personnel available" due to illness.
Outbreak of infections in Jinotega
Despite being the largest department in the country, independent statistics show that Jinotega is not one of the departments most affected by covid-19. During the first year of the pandemic, there were 666 infections and 148 deaths.
Health personnel were little affected. According to the observatory, between March 18, 2020 and March 18, 2021, there were 17 infections including 10 doctors and two nurses. Without any deaths. However, the numbers increased since then, alerting of a focused outbreak. This revives fear of the pandemic epicenter which was reported in Chinandega in the early days of the pandemic.
"Not having been hit hard last year, perhaps a percentage of the population remained unrelated to the virus. And, during this second outbreak, there were fewer people immunized, because of herd immunity, due to the fact that they did not receive the initial viral load that somehow protected the population," says Dr. Perez.
Doctor Josefina Bonilla explains that " the logic of epidemics like this one first attacks places of high agglomeration, such as cities, but, as time goes by, due to internal migration, infected people arrive in more rural municipalities, less densely populated. It only takes one contagion to affect families in a rural area. We are seeing more cases in less urbanized places, compared to the first year of the pandemic.
Added to this is the fact that not all hospitals have a triage system in place to avoid contact between patients with suspected covid symptoms and others.
According to the Observatory, in the last month, thirteen nurses have been infected in Jinotega, two of whom died presumably from covid-19. This increase in infections and deaths among health personnel and the population has increased protection measures.
"The protocols have been activated. They are demanding the use of masks and hand washing a bit more, especially among health personnel. They are demanding the use of masks to the population in general and the visits were restricted", explains the medical source.
In Nicaragua there is a lack of personal protective equipment
Managua is the department which has registered the highest number of infections and deaths from covid-19 in the health sector in the entire country. In the last month, 16 doctors and 10 nurses have been infected. This increase could be explained by exposure to the virus and limitations in personal protective equipment.
"The public services provide a limited number of masks, insufficient for the real need. Doctors and health personnel have to contribute with their own resources to buy material for self-protection. By not addressing the pandemic as a national emergency, no financial resources are allocated to protect doctors and health personnel, including laboratory technicians, nurses, orderlies and other positions that are directly related to patients," says Dr. Josefina Bonilla, who is president of the Nicaraguan Medical Association and a member of the Multidisciplinary Scientific Committee.
In hospitals that do have protective equipment, there are also deficiencies. "For example, at Monte España Hospital, the quality of the equipment they purchased in the first wave was bad and they are still using the same equipment. It’s reusable protective equipment and they have been washed thousands of times so then the quality drops even more. There are probably more cases, but we have not noticed because it’s hidden," says a source from that hospital.
Nationally, the departments that have reported the most infections since the beginning of April 2021 are: Managua, Jinotega, the Northern Caribbean and Chinandega. The number of front-line personnel who have already received the first dose of the vaccine is unknown. But despite the fear that exists in the medical profession due to state surveillance, the truth continues to come out to the public.
"Information during a pandemic is even more useful than in regular times and unfortunately the flow of information through the official channels does not exist, but alternative mechanisms are used to obtain at least part of the information, that helps us to orient the population and the medical and health profession", says Dr. Bonilla.