Wages in Nicaragua

The Nicaraguan Gross Domestic Product in 2005 was $4.9 billion dollars, or about $860 dollars per person.
This modest amount implies that wages must be very low and this is the case. 


According to WHO data, the average monthly minimum wage (Nicaraguan Cordobas converted to Canadian Dollars) in 2006 was $45 for an agricultural worker and $101 for a fisherman. This information supports other data that I have read that a substantial percent of the population earns less than $500 a year. The WHO also reports that the average cost to meet the basic nutritional needs of a person is $133 a month. Therefore those individuals who are paid the minimum wage are starving.  



The child labor market includes an estimated 240,000 children and adolescents of whom 61.4% do not receive any remuneration at all. 


Many Nicaraguan men work in Costa Rica, where the wages are much higher. The economy in Costa Rica has blossomed in the last few decades courtesy of tourism and foreign investment. The Nicaraguan government has actively encouraged tourism and foreign investment since 2006. Americans, Canadians, Australians, and Europeans are traveling to Nicaragua in record numbers. American Airlines recently started a non-stop flight to Managua from Miami.


The clinic where I help out is located in Limon, a community on the north-south Pacific coastal road. The clinic is only about five km inland from the coast. The region has a lot of tourist potential. San Juan del Sur, a coastal community further to the south has boomed over the last decade and now has cruise ships that stop every week.


The low cost of land and labor are attractive for foreign investors. I have talked to numerous Americans who have built or who are building in Nicaragua. The current wage for an unskilled worker at a building site is $150 a month. Doesn't sound like much, but this is at least more than the cost of the basic nutritional needs for an individual. However, what if this person is the sole wage earner for a family of 4. That means the family is still starving. 


Tourism and foreign investment imports much needed dollars into Nicaragua and increases employment at higher than the minimum wage. Is this good? The money and employment is good, but there is always a cost. The Nicaraguan people are selling their prime real estate to improve their standard of living.

Blue Crab, Callinectes sapidus, watched me carefully for a moment,

then disappeared into the sand within a few seconds.   

Pan American Health Organization (PAHO) Data 2008

Health Systems Profile - Nicaragua

Monitoring and Analyzing Health Systems Change

Pan American Health Organization/World Health

Organization PAHO/WHO

May 2008

MINSA is the Department of Health in Nicaragua. MINSA targets primary and secondary levels of care in Nicaragua. This makes sense. When the resources are limited, the best approach is to focus on the basics. However, this implies that tertiary level care is not available to the public, unless this is provided by a private physician, clinic, or hospital. This means for instance, that dialysis would not be available for a child with kidney failure.

The table below outlines who pays for the health care in Nicaragua. MINSA pays for the majority. The total does not add up to 100%, which implies that no one pays for the missing 20%. This actually might imply that one fifth of the population does not receive any care! I suspect that these are the individuals who are not registered with MINSA. Unless you have a number you do not exist. This is a real concern because without a MINSA registration, an individual cannot access care, and individuals are actually turned down in this situation. Ridiculous bureaucratic obstacles exist in every jurisdiction. 

	Percent
MINSA	60
Nicaraguan Social Security Institute INSS	8
Government and Military	8
Private	4
Total	80

MINSA has a list of essential drugs and reviews what should be included every two years. MINSA likely only chooses generic medications. Cutting edge (read expensive) therapies are not likely considered. Every month the local MINSA physician reports data on the patients and medications dispensed and the supply for the next month is based on this data. I learned that the supplies always run out well before the end of the month. I imagine the more organized patients turn up in the first week to obtain their chronic medications. 

The inventory of equipment at the first level of care fails to meet user demand for these services. My experience certainly confirms this. 

At the second level of care serious obstacles hinder efforts to maintain existing equipment, including a lack of qualified equipment maintenance personnel. I am sure this is the case. There are no parts or personnel to fix any out-of-the-ordinary mechanical or electrical device, much less sophisticated medical equipment. For example, if I were to purchase a car in Nicaragua, there are only a few makes and models that would routinely have parts and service available. Why would anyone purchase something different?   

Physicians per 10,000 population increased from 4.0 in 2000 to 4.7 in 2007. By comparison, the number of physicians in Canada per 10,000 population is 22. 


In 2007 there were 1376 male physicians and 1231 female physicians in the public health sector. Many of these are brand new graduates. I learned that physicians who graduate from medical school in Nicaragua are obliged to serve for two years in a MINSA clinic. The physicians are posted to a clinic immediately after they graduate and the public service is therefore their postgraduate training program. I graduated from a first class medical school that included a lot of clinical experience prior to graduation but I spent 6 more years of postgraduate training before the Canadian Medical Profession let me practice my specialty without supervision. For general paediatrics at that time the minimum duration was 4 years and for family medicine the duration was 2 years. Posting brand new graduates to meet community needs sounds ridiculous, but any knowledge and help, however inexperienced, is better than no knowledge or help.

Great Egret on a windy day.
The wind is only apparent with the feathers behind the neck.
The branch was really swaying and the egret needed to
brace the legs and lean into the wind to keep steady. 

  

Community Outreach Program

This trip was far more successful than my prior efforts. Experience counts.

From the outset I decided that I wanted to find a location where I could return and continue to work as a paediatrician. I desired continuity.

I did not aspire to visit foreign places once and then move on, although this is the most common pattern for a medical volunteer. For some volunteers the destination country is the reason for the trip and each volunteer opportunity is a location on the volunteer’s bucket list. I get that. Help is help and always appreciated.

However, for me, I desired continuity. I knew that continuity would educate me and that really making a difference always requires knowledge. When a patient returns improved this is affirmation of success; when a patient returns and is not improved, this means I need to improve. Continuity is a great teacher. My ground rules are to improve the quality of my care with each subsequent visit. There is no reason why I cannot continue to improve. 

I have only seen a tiny tip of the iceberg of poor health in the region. The mothers who came to the clinic had to hear about my visit and they needed transportation. Communication and transportation are key issues that need ongoing improvement.

One way to improve transportation and communication is for me to travel to the patients. If I travel to a community, this solves the transportation problem and local communication will be simpler. As such, with my next trip I want to start a Community Outreach Program.

The Goals of the Community Outreach Program will be Paediatric Health Screening and Paediatric Health Education

Paediatric Health Screening

Check the immunization cards of the children.

Check height, weight, and head circumference and plot the data on a growth chart.

Check a stool specimen for parasites and worms.

Check a dipstick urinalysis.

Children with abnormal screening tests will be referred for follow up to the Clinic.

Paediatric Health Education

Essentials of good nutrition

How to disinfect water with SODIS

How to prevent worm disease

How to use oral rehydration solution

How to treat fever

Provide Basic Medications for Every Child

1. Multi-vitamin - two month supply

2. Acetaminophen with Spanish instructions on dosage

3. Oral rehydration solution packets sufficient to make two liters with Spanish instructions on how to prepare and use

With the approval of the mother, every child could be treated for worms with mebendazole 
and for parasites with metronidazole. 

Gaby Organized the Toys for the Children - Thank You!

Gaby is a 10 year old girl who visits my office. She is a terrific gal. The acorn doesn't fall far from the oak, and her Mom is wonderful as well. When Gaby and Mom found out I was on my way back to Nicaragua, Gaby purchased some toys for the children. The photos show children enjoying her generous gifts.  


Thank you Gaby. 

Snakes, Scorpions, and Spiders

These animals are all Scary and the first letter of each name starts with an “S.”  A Silly coincidence.


Over the last week I have had two of these creatures in my casita. I don’t walk barefoot!

White-fronted Parrots in Flight.

I have not seen a snake in Nicaragua. Every morning I start my bird watching at 5:30, before the dawn breaks over the horizon. I walk briskly for about 30 minutes to an area along a stream (a deep and wide river in the rainy season). I spend an hour looking at the birds and then I walk back to the casita to get ready for the clinic. Most of the hour is spent on paths in the jungle. I am constantly on the look out for snakes. Every hanging vine and piece of wood on the ground is suspect.


About a week before I left for Nicaragua I listened to a very funny TED talk by Douglas Adams, the famous author of “Hitchhiker’s Guide to the Galaxy.” He also wrote, “Last Chance to See,” a book about endangered species. Adams visited the locales of all the endangered species he wrote about and since he was going to Madagascar, a place filled with deadly snakes, he consulted a world authority on snakebite. Adams’ anecdote about meeting with the Australian Herpetologist (snake expert) was hilarious. Adams asked the expert what to expect if he were to be bitten by a deadly snake.


“You die of course," the expert replied, "that’s what deadly means.”


The audience roared with this comment and so did I. However, the grim reality is that some snakebites are deadly and Nicaragua is home to a dozen or so the most deadly snakes in the world. There are 10,000 to 100,000 reported snakebites in Central America every year and of course most bites in underdeveloped countries are not reported.



So, I’ve decided that it is not a matter of IF I come across a snake, but rather WHEN and HOW OFTEN. My desire is to minimize encounters.


I do a lot of stomping when I walk in the jungle to send vibrations ahead to let the snakes know I’m around. I make noise. Stomping and noise doesn't help with bird watching. I do not move fast. I want to give the snakes lots of time to move. The same rules hold for preventing grizzly attacks back home. There should be Snake Spray.


The conventional acute care for snake bite is to immobilize the extremity, usually a leg or hand, to apply a pressure bandage with sufficient pressure to stop the return of the venous blood to the heart but to allow the arterial flow into the extremity, and to elevate the leg or arm.

Orange-fronted Parakeet Eating Flowers

I get asked a lot about snake anti-venom. Years ago, when I was backpacking in Thailand, I visited an anti-venom center. Handlers milked the venom from the various vipers and the liquid was sent to labs to prepare anti-venom. There could theoretically be an anti-venom for every snake and there are a number of products available, but none are approved by the US FDA and all are considered experimental because there are no good studies to prove if, or how well, the preparations work. To be effective at all, the anti-venom should be administered within 4 to 6 hours. Of course the anti-venom must be available locally and you must be able to identify the snake to choose the correct anti-venom.


Imagine a bird watcher person like me who is bitten by a snake on his leg in the jungle. The medical books suggest that the snake should be identified with a photograph. How many people bitten by a snake hang around to take a photo? The snake would likely slither away. Do you think that someone who was bitten would chase after the snake to take a photo? I don’t think too many snakes are identified by photograph.

The next question is how would this person immobilize and elevated the leg? That is not possible unless there is a convenient stretcher and four able-boded men to carry the person. So, this means that the only acute intervention would be a pressure bandage above the lesion, and a speedy retreat to the nearest anti-venom place.


The nearest anti-venom location is likely in the US. How fast do you think a person in Nicaragua could get from the jungle to the US? Could this be accomplished in less than 4 to 6 hours? Hmm. Not likely.

This all means that prevention is the key to survival.

White-fronted Parrot

Poverty, Child Labor, Child Prostitution

Poverty in Nicaragua is a serious obstacle to social progress.

During 2002 to 2007, only half of the children who started grade one finished primary school. Children did not finish school because of school fees the family could not pay or because the child quit to work and help support the family. Farms and mines regularly use child labor. Since Ortega was re-elected in 2006, the school fees have been free, so hopefully this will improve.

About half of the adult households in Nicaragua do not have an adult male present. Marriage is not an expected outcome for relationships.

During my first trip to Nicaragua in October 2010 I rented a residence and the owner provided a woman to cook and a man to care for the grounds.

The woman was in her mid-twenties, good looking, spoke much better English than I spoke Spanish, and her cooking was terrific. I was interested to learn about the country and asked her a lot of questions. She was not married but she had three children, each with a different father. One father was Nicaraguan, one was German, and one was American. The German had stayed in Nicaragua for a year or so. The American was a GI who had visited the country. The mother was not embarrassed to explain about three fathers and three children. She was pleased about the two foreign fathers because both sent money to provide support for their illegitimate child. The youngest child was a 13 month old infant and the mother was planning to send the child on an airplane to the US to spend a month with the single father who was still living in the home of his parents. Presumably the paternal Grandma was the designated care person. A non-related Nicaraguan who was traveling to the US accepted the responsibility to care for the in-transit infant. I was appalled, but the mother didn't blink an eye as she told me this story. I wondered if perhaps she expected, or perhaps hoped that the baby might remain in the US? The German and American fathers provided dollars and Euros and this was what was important. After the first few days in Nicaragua, I realized that the woman was flirting a bit with me and I wondered if I had been identified as potential father and supporter number four?

This mother's values were very different than mine, but I realized I should not judge her by my standards.  She was part of an emerging Nicaragua middle class. She was bilingual. She was self supporting. Her children were well fed and clothed and the oldest attended school. Perhaps the baby will be raised up in the US? I am fairly sure her children will be more successful for her efforts.

Other mothers sell their children into prostitution to earn money. Which is better? Should the mother prostitute herself for her children, or should the mother sell her children into prostitution?

Daniel Ortega, the President of Nicaragua, is a known philanderer, apparently with the full knowledge of Rosario Murillo, his partner of four decades. Worse, he has been accused of sexual abuse by his wife's daughter, who in 1998 accused Ortega of molestation and rape from the time she was 11 years old. Amazingly, her mother supported Ortega and she continues to support him notwithstanding these allegations. The support implies tacit approval of Ortega's actions, which no one apparently doubts. In Nicaragua, men sometimes claim sexual rights over a daughter from a previous relationship. When the leader of the country models this behaviour, what can we reasonably expect from the men of the country?

Very Young Mothers

Today the most worrisome child was the last child. Grandma brought in a seven day-old infant. The Mom was in the next room with an OB GYN Physician Assistant from San Jose, who helps out at the clinic several times a year.

Grandma reported that the tummy of the baby felt hollow when she tapped on the abdomen. She advised that the baby had not gained weight in the first week, which is not unusual, but the baby looked tiny and tired. Grandma could not answer all the questions and so I waited until Mom was available. When Mom walked in she was about 15 years of age. This was her first baby, and she was floundering with breastfeeding. She explained that the baby only fed twice during the daytime, or about every 6 hours, and was otherwise asleep, and then she fed every hour or two over night. The baby only fed about two minutes at a time. Babies need to feed often or their blood sugar falls, which can lead to tiredness and worse. I asked Mom to show me how she breastfed and then we reviewed the importance of latch and good positions. I asked Mom to show me how she burped the baby and I corrected her approach. I explained the basics of the frequency and duration of breastfeeding to Mom and Grandma. We arranged for the baby and Mom to be reassessed and weighed in a week at Las Salinas. This baby is a very high risk for failure to thrive. 

I saw two infants who were brought in for well baby checks by their pregnant Moms. The Moms were at the clinic to see the OB GYN Physician Assistant. One baby was 4 months old and the other was 5 months old. These Mother were pregnant within several months of delivery and they will deliver two babies in less than a year! Ouch! I’m glad the OB GYN Physician Assistant is available to help them with birth control.

Today was mostly a well child check up clinic. There were some coughs and colds. We saw 13 children including one follow up.

  

Bedwetting in Nicaragua

A nine year-old girl was brought in by her Aunt because she wet her underwear by day and her bed at night. Seventy-five percent of my Calgary practice is day and night wetting, so this was a terrific opportunity to compare the cultures. There was no difference. The girl only pooped once a week and she drank only 500 ml a day. This is so predictable back home and great for me to confirm in Nicaragua.

This week I saw two toddlers with Herpangina, a throat infection caused by Coxsackie virus. Coxsackie virus is common in Canada and is more often seen in the summer months. Now is the Nicaraguan summer. The virus causes a fever and sore throat and the there are tiny sores in the back of the throat on the palate that are diagnostic of the infection. The tiny sores are white circles surrounded by a red area. When only the throat is involved the infection is referred to as Herpangina. Sometimes there is a rash on the soles of the feet and the palms of the hand and in this situation the infection is called Hand Foot and Mouth Disease. 

Antibiotics will not help and fever control and hydration are the mainstays of treatment.

I cannot believe my two weeks is almost over. Seems like I arrived yesterday. Time flies when you’re having fun.

Tic Toc - Waiting on the Tick

When I showered I felt something in my groin and flicked it off. Looked to me like a green seed pod but when I stepped on the pod a lot of blood spurted out. My blood. Ouch.

It was a tick. Specifically, the tick was Amblyomma cajennense. This tick is found mostly in the jungle and likes to prey on animals.

Amblyomma cajennense

There was a small black central puncture wound with an area of redness around the bite that was about half a centimeter wide.

I had showered for dinner the night before and surely would have noticed the tick then, so my thoughts are that the tick arrived overnight, perhaps picked up in my clothes earlier that day. As this thought settled, I recollected an itch in the same area overnight. The itch was likely the bite. I didn’t check the time, I just rolled over and went back to sleep. I only slept for six hours that night, so the tick was attached for a maximum of six hours and this detail is important because the duration is correlated with the risk of infection with Rickettsiae rickettsia, which causes Rocky Mountain Spotted Fever, or just Spotted Fever in Latin America.

I immediately took some clarithromycin, which I had on hand, and the next day I obtained Doxycycline, which is the recommended treatment.

The incubation period for Rocky Mountain Spotted Fever ranges from 3 to 12 days. The tick needs to be attached for 2 to 10 hours for the Rickettsiae to be released from the tick salivary gland and an earlier onset of symptoms occurs when there is a large volume of the inoculum. I likely have a low risk for infection, but there is a risk. I will just have to wait and see. 

Tic Toc - waiting on the Tick.

Fisherman Walking Home at Sunset

Interpreter Success

My decision to hire interpreters for this trip to Nicaragua was a good one. I feel more confident that the mothers understand my recommendations.

The interpreter this week is Jessica Southern. Jessica is not only bilingual, but she is an American paediatric nurse. Wow! What a great combination for my work! Jessica works for FIMRC, a US charity, at the Las Salinas community clinic, but the clinic is closed this week, so she kindly agreed to help me. Jessica is terrific.

We saw 9 patients today and we saw them in 5 hours, which is fast compared to past visits. I typed out the basics of the treatment plan and Jessica communicated the recommendations to the mothers. After two days, we are a good team. This was my best clinic day yet!

The sickest child was a boy with a history that suggested urinary retention. He had past history of treatment for urine infection and kidney stone. I hear these diagnoses a lot and the histories do not usually fit with these diagnoses. My sense is that any urine problem in Nicaragua is diagnosed as infection or stone or both. The boy was 12 years old and had pain severe enough to make him cry. During the episodes of pain he felt as if he needed to pee but he could only pass small amounts. His urine today did not show infection or blood, and he had an episode last night, which makes infection and stone unlikely. He had a very narrow pee hole at the end of his penis. Jessica arranged for him to have an ultrasound at the Las Salinas clinic and to see the pediatric surgeon who comes up from Rivas once a week.

A fourteen-month old boy was brought in for recurrent hives, which Mom was convinced was due to beans, beef, and shrimp. From the age of 8 months he has experienced itchy bumps. He had typical papular urticaria, which is usually an allergic or immunological response to insect bites and not usually to food. The clinic pharmacy had an anti-histamine, which I asked Mom to give him at bedtime on the real itchy days.

A 12 year-old boy came in with typical migraine. He told me the headaches were much worse when he was walking on really sunny days. The sunlight in Nicaragua is very bright and I have no doubt this would aggravate the headache in any person with migraine. Poor hydration likely also plays a role in his headaches. I treated him with Naproxen and Jessica reviewed the migraine- teaching handout I prepared with Mom.

The days whiz by in the clinic. This is no different than at home. One child after another until the waiting room is empty.

Most of the children today did not have a chart at the clinic, which means this was their first visit. They came to see the Canadian Doctor.

This immature Tri-colored Heron was fishing in the late afternoon. 

The sun was very bright and the bird opened up the wings to create a shadow so the fish in the small pools would be easier to see. 

  

Prevention. Prevention. Prevention.

Dad brought in his five year-old son with fever and sore throat.
He had the typical vesicles of coxsackie virus. The throat is very red and sore, and the neck glands are enlarged. Unless the typical vesicles are noted on the tonsillar pillars, many children are treated with an antibiotic as per strep throat, but this is a virus, lasts a week,
and fever control and hydration are all that is necessary. 

I now have contacts in the region. Bo Fox, who I met on the last trip, and Sheyla and Jessica, who help as interpreters with this visit, live in different

communities in the region. Within an hour of the clinic, there are seven communities along the dirt road to the north or south. At the next visit I will try to organize community teaching sessions on a variety of common paediatric topics.

Back in Canada I will develop a PowerPoint presentation in Spanish and on the next trip we will find community locations with electrical power, hopefully a fan, and enough room and chairs for local mothers to come. We will advertise the sessions locally for several weeks before the event. I will plan a two-hour session and cover four basic topics. After each thirty minute session, I will answer questions. We will provide water, juice, and nutritious snacks for the families. Sounds good. Hope we can do this. 

The basic topics I will present will include: 

1. how to disinfect well water with SODIS. 

2. how to prevent worm disease. 

3. the principles of good nutrition.

4. the principles of good hydration. 
5. how to use oral rehydration solution for diarrhea.
6. how to treat fever.

Every Mother will be asked to bring the immunization cards for her children and we will check the immunization status and advise the mother if she needs to get caught up at the next public immunization day in her community.

Every mother who attends will be provided with: 

1. Mebendazole, three day course, for worms

2. Metronidazole, three day course for parasites

3. Multivitamin for two months

4. Acetaminophen to have on hand for fever 
5. Enough Oral Rehydration Solution powder to make two litres. 

5. Spanish teaching handouts on worms, parasites, nutrition, hydration, fever, and diarrhea. 

Howler Monkey who watched me very carefully this morning.

The loud roars of the males at dawn and dusk can be heard for miles 

and serve to delineate territories. 

Foot Wounds on the Beach

Many Nicaraguans walk barefoot, which seems impossible to me, but I see this all the time. The pathways, the beach, and the dirt roads are definitely not foot-friendly for Gringos like me. Nicaraguan soles must be like leather. 

Over the last two days I was asked to assess two Americans with foot injuries. 

A middle-aged man was stung by a sting ray as he was walking in the surf. He felt severe pain and pulled out the stinger from the side of his foot. His fingers started to tingle from the venom and he dropped the stinger. He described the pain as the worst he ever experienced. The puncture wound at the side of his foot was surrounded by a black area about 2 cm by 1 cm. I did an Internet search on sting ray wounds and venom and learned that for foot injuries the most serious common complication is if the stinger penetrates the bone which can lead to osteomyelitis (bone infection) or if the stinger breaks off and leaves a foreign body which invariably gets infected. The worst aspect of the acute injury is the severe pain, which is ameliorated by intense heat. I checked with the fellow the next day and he was feeling great, so infectious complications are not a concern. 

The second person was a high school senior who stepped on something sharp on the beach. He had a very painful, hot, swollen area below his third toe and when he moved the toe, the pain was intense, which implied the tendons or muscles that controlled the toe were inflamed. I treated him with ciprofloxin, anti-inflammatory medications, hot soaks, and elevation. I checked on him earlier today and he is improved with less tenderness and swelling. All good.

Snowy Egrets must have tough, no slip toes 

             because they land on the beach and rocks with no problem. 

Sexual Predators in Nicaragua

Tim Rogers is the Editor of Nicaragua Dispatch, an excellent online daily that provides news in English. I met Tim during my April 2011 trip to Nicaragua. Recently he featured an article on child sexual abuse in Nicaragua. 

http://www.nicaraguadispatch.com/features/sex-predators-find-easy-prey-in-nicaragua/1498 

The article featured a photo of an arrested sexual predator and I realized immediately that I had seen this man during a trip to Granada. 


Granada, the fourth largest city in Nicaragua, was founded in 1524 by the Spanish, and the history, architecture, and location on the shores of Lake Nicaragua make the city an important tourist destination. The central square is bounded by a beautiful cathedral and several prominent hotels. The plaza is busy with lots of vendors who sell leather goods, jewelry, pottery, nuts, t-shirts, and other tourist stuff.

In October 2010, I spent a tourist afternoon in Granada. I noticed a middle-aged white man and suspected immediately that he was a predator. He was sitting with a ten or so year-old Nicaraguan boy on a park bench. The boy looked self-conscious and held his head down without making eye contact with the man. Everything about this scene was wrong. I wandered in and out of the central plaza over the course of an hour or two and I saw the man again with another child.

The plaza was filled with adults and there were lots of children who were selling merchandise on behalf of these adults. No one seemed interested at all in either the man or the child, which seemed so strange. Don't the Nica adults see what is going on? 

On the one hand I felt as if the rest of the adults in the plaza must be blind. There were numerous security people outside the hotels that ringed the plaza, and the Granada Police were routinely present in the square, and they all cast blind eyes on the situation. 

Then I wondered, Oh my gosh, is this just the way it is in Nicaragua?

In the article, Tim Rogers reports, sadly, that this is how it is in Nicaragua.

This Variegated Squirrel chattered at me

                                          during my morning walk.