Michelle Alyssa Tran, Rice University
I. Background:
Nicaragua
Nicaragua is the largest but most sparsely populated country in Central America, flanked by the Caribbean Sea and the Pacific Ocean and bordered by Honduras and Costa Rica. The country has a diverse geographic makeup with its volcanic and fertile Pacific coast contrasting its swampy Caribbean coast. Nicaragua is also home to several mountainous regions and two large lakes, Nicaragua and Managua. It is divided into 15 departments, 2 autonomous regions, and 153 municipalities, and its capital city if Managua. The majority of the population lives in the western Pacific lowland region between the Pacific coast and Lake Managua.
Nicaragua is the second poorest country in the Western Hemisphere after Haiti, with 48% of the population living below the national poverty line. As of 2010, 57.2% of the population was reported to live in urban areas with 45.5% of this urban population living in the slums. Nicaragua is still largely an agricultural country, but its nontraditional exports (tobacco, gold, textiles) have increased over the past few years. Most of the population is Mestizo and Spanish-speaking. The Catholic Church plays a dominant role in society and is the religion of the majority of the population.
Nicaragua has had a conflicted and anti-democratic history, but currently has a constitutional democratic system presided over by Daniel Ortega, who has retained his position since 2006. Nicaragua was first settled by the Spanish in the early 16th century and was under Spanish rule until it achieved independence in 1838. For the next century, political unrest, civil war, natural disaster, corruption, and economic instability plagued the country, several issues of which remain present today.
During this time, the United States made a controversial appearance on the Nicaraguan political stage, which was dominated by competition between the Liberals in León and the Conservatives from Granada, which were backed by the U.S. government. The socialist Sandinista party was in power for the majority of the 1900s, and in 1981, U.S. President Reagan authorized covert support to the Contras, the anti-Sandinista forces. In 1982 the Contra, trained by the U.S. CIA, began assassinating high-level Nicaraguan government members. The interventions of the U.S. government resulted Nicaragua pursuing a case against the U.S. in the International Court of Justice, which ultimately ruled against the U.S. and further strained U.S.- Nicaraguan relations.
U.S.- Nicaraguan relations have improved since then, and today the two countries cooperate on counter-narcotics, trade, and security matters. The United States provides significant foreign assistance to Nicaragua, helping out extensively with humanitarian relief efforts after Hurricane Mitch in 1998 and providing the country $50.2 million in aid in fiscal year 2006. However, it will still be important for me to cognizant and sensitive of the strained historic relationship between the U.S. and Nicaragua so I do not overstep my boundaries as a U.S. visitor to the country.
Adolescent Sexual Health in Nicaragua
Nicaragua has the highest rate of teenage pregnancy in Latin America with 28% of women giving birth before the age of 18. Maternal mortality continues to persist as a significant issue in Nicaragua, with adolescents accounting for one third of all maternal deaths. Out of these deaths related to pregnancy, childbirth and the postpartum period, around half occurred in public hospitals and other treatment facilities with the remaining having occurred at home or other public places. In respect to sexual activity amongst Nicaraguan adolescents (15-19 years), 39% of have had sex, and of these, 13% had started before age 15. Of adolescents with sexual partners, 46% already had at least one child, and only 30.7% had ever used a contraceptive method.
These concerning trends are considered to be resultant of several sociocultural forces. Since the Catholic Church remains a powerful force in the nation, abortion is completely illegal, without any exceptions granted on behalf of mothers’ health. There also exists some religious prohibition of contraception. Furthermore the machismo mindset continues to cultivate the traditional view that Nicaraguan men should prove their virility by fathering numerous children without any societal expectations to marry their mothers or support their newly created families fiscally or otherwise. Sexual violence against girls is a contributing factor to this high pregnancy rate. Out of over 6,000 cases of sexual violence in 2014, 88% of these cases involved young teenagers.
While the Nicaraguan National Health Plan acknowledges that adolescent pregnancy is a problem, it has failed to offer any solutions. Current existing efforts are small, inconsistently funded, and not supported well by the government. There continues to be no formal sex education in schools, and pregnant girls can be summarily expelled from schools. Additionally, limited access to health care and education for families and adolescents, especially amongst the indigenous and in rural areas, are key issues that prevent women from receiving regular or emergency medical reproductive general services and screening; in rural Nicaragua, the majority of women in rural areas (65%) are illiterate and with most (55%) giving birth at home instead of at public medical centers. In these poorest and most isolated regions, infant mortality remains high. For the indigenous Nicaraguan population there is a 25% illiteracy rate with pressing health issues of poor housing conditions, overcrowding, and lack of electrical service.
While working on a sexual and reproductive health adolescent education program at an urban health center in Masaya, Nicaragua, I should be cognizant of the limiting social and cultural forces that I must work around. Cultural sensitivity will be integral to my project’s success, and I must take the time to gauge the local attitude towards women’s responsibility to use contraceptives and receive regular well-women exams before jumping into my work. Especially for my outreach projects for surrounding rural communities, I should be aware of infrastructural issues that perpetuate the communities’ lack of access to regular medical services and develop curriculum accordingly.
II, Breaking News:
Nicaragua accumulates 70 positive cases of Zika
El Neuvo Diario, February 17, 2016
The Zika virus is making headlines and arousing fear amongst communities worldwide. Because of its rapid spread throughout Central America, the Zika virus is dominating the Nicaraguan news. It is of utmost importance that I keep updated on Zika developments and WHO and CDC recommendations before working at the Masaya health post this summer. Zika will likely be a pressing concern for community members, male and female alike. Furthermore, due to recently proposed links between microcephaly birth defects from mothers who had Zika-like symptoms during their pregnancies, there may be more young mothers-to-be, mothers, and other females who will likely be worried about safe contraceptives or about how this virus may affect their sexual and reproductive health.
This particular recent article (published February 17th, 2016) discusses how seventy cases have been reported in Nicaragua so far, with four new cases having arisen within the previous 24 hours alone. The Ministry of Health is currently playing an active role in responding to this public health crisis by pursuing a comprehensive campaign to eliminate mosquito-breeding sites. This campaign specifically involves spraying in areas where dengue or chikengunya Zika virus have been reported. Health Ministries of Central America are currently collaborating and discussing on how to best work together to best respond to Zika to keep citizens healthy.
As community members may seek to gain more information and facts about Zika from a local family health clinic, it is integral for me to be aware of this situation and be up-to-date about ways to prevent Zika before leaving to Nicaragua. I may also consider addressing this virus as part of my female health curriculum. I must be wary of this health situation and knowledgeable about recommended preventative precautions, so that I may protect myself against infection while there for the summer.
“The Ministry of Health trains 500 health graduates and 700 midwives”
El Nuevo Diario, January 6, 2016
The Nicaragua Ministry of Health recently announced their new initiative to train and certify 500 health graduates and 700 midwives to address emergency situations throughout Nicaragua, especially in rural communities. This program involves selecting students from rural schools that will be committed to working in Nicaragua after graduating through special work contracts. The Ministry of Health’s plan involves training these students on first aid so that they can respond to a range of types of emergencies, including small house incidents to larger-scale disaster situations. Beyond identifying new students from schools, they also hope to certify already existing community health leaders including medical volunteers, traditional healers, brigaders, and others who collaborate with the Ministry of Health.
This article sheds valuable insight onto the community-based health priorities of the Nicaraguan Ministry of Health. The Health Ministry seems to be attempting to build-up community medical support systems and encouraging their workers to stay and practice within their places of birth rather than leaving to other more developed regions or countries. Through identification and medical training of community members, this national program appears to be focused on building community trust from within, an important aspect of their national medical care that I hope to learn more about firsthand this summer. This new training program may or may not affect the Masaya health centers or partner centers in surrounding areas, but it is still useful to be aware of this program so that I may engage in meaningful discussion with doctors and other community leaders while there. This article was also another reminder that I must always keep in mind the importance of implementing sustainable programs that are community-based and community-driven. Cultivating trust through friendship will be important for my project’s success, especially when focusing on such a sensitive topic as healthy sexual and reproductive hygienic practices.
“Nicaragua’s Construction Sector Expected to Improve Through 2016 and Beyond”
LatinOne, February 15, 2016
Nicaragua’s construction industry grew 18% in 2015 and is expected to grow another 17% this year, a positive trend that has been attributed to the presidency of Daniel Ortega. This article mentions that this boom is evidence that the country has been steadily recovering from poverty after a history setbacks due to interventions led by the U.S. and multinational corporations. Beyond an increase in private construction projects, Nicaragua has several major national construction projects scheduled for 2016 and beyond. One of the more advertised projects is a 170-mile long inter-oceanic canal, a $50 billion canal hydroelectric project that is backed by China. The goals of this project is to attract larger vessels that do not fit through the Panama Canal to help lift Nicaragua’s current $12 billion economy. At the conclusion of the article, the article reports that there have been protests against the building of this canal, with 34% of Nicaraguans believing that this project is “pure propaganda” and purely a self-advertising method for Ortega to regain presidential election this November. However, article mentions that the government published a separate contradictory statistic that indicated that 81% of Nicaraguans supported the building of this canal.
The president’s recent updates about his commitment to pursuing the canal project have several implications for my internship experience in Nicaragua. First and foremost, it is for me to be aware of the political unrest that has resulted from the announcement of President Ortega’s commitment to the building of the Nicaragua Canal. My partial Chinese descent could perhaps result in misdirected animosity towards me. The lack of transparency about the financial feasibility of the project has seemed to raise distrust amongst Nicaraguans directed towards their government and its partnership with the Chinese. This has likely raised suspicions that this is more of a commercial security project for China than an economic project for Nicaragua. Either way, it is important that I am at least familiar with this project so that I could participate in basic discussions about the project with others during my stay there and protect myself. Furthermore, the building of this canal would have significant impact on the environment and therefore the health of Nicaraguans. From what I have previously learned, the building of this canal will require the dredging of one of the nation’s most critical water source, Lake Nicaragua. This reduction in access to clean water could have dire health consequences for the nation’s population. With all things considered, I should keep updated on this controversy that is currently playing out between the Nicaraguan government and citizens from both health and political standpoints.
“Hyatt businessman shows interest in continuing to invest in Nicaragua”
El Economista, January 29, 2016
The construction of a new Hyatt Hotel, the first Hyatt Hotel in Nicaragua and the second Hyatt Hotel ever built in Central America was just completed in Managua. This project was prompted by a desire to make the city an international meeting point for corporations and construction. The article discussed how the LATAM Latin American Hotel Corporation that partnered with the Hyatt recently expressed their interests in increasing their investments in Nicaragua. The reasons for their interest in Nicaragua stem from the nation’s high economic growth, especially relative to its other Central American nation counterparts. Over the past three years, the Nicaraguan economy grew at a 4.7% rate, exceeding the Central American average rate of a 3.7% growth. The president of the corporation reported that Nicaragua’s high security, wealth of appealing hotels on the coast, and the varied natural beauty contribute to its value as a prime tourist destination worth investing in.
Though I will be living and working in Masaya, Nicaragua summer, it would be beneficial to be aware of the changing dynamics of the nation’s capital city. Though the article touches upon the economic benefits that Hyatt’s expansion into Managua will have, it does not go into much detail about the opinions of the Nicaraguans on the increased commercialization of their country. The increase of tourism and international visitors in the city may or may not be something that the citizens of Managua or citizens of other areas in Nicaragua will welcome, and this is something that I should be wary of as an American traveler. Furthermore, it is valuable to know that capital is evolving more and more into an international hub; the city’s rapid economic growth as well as its citizens’ increase in exposure to international visitors and international cultures could affect the health of community members as well as change their lifestyle values. These changes might influence other regions of Nicaragua as well. These are all considerations that I should think about as an American traveler to the Nicaragua this summer.
III. Local Faculty Connection:
To gain some insight into working on women’s issues in Nicaragua, I spoke to Dr. Cymene Howe, an Associate Anthropology Professor at Rice. Starting from a brief undergraduate experience in 1990 and continuing after, she has spent over ten years researching and serving in Nicaragua with various organizations including Casa de la Mujer, a women’s health and rights organization that has a network of clinics throughout the nation. Based on her research there, she published Intimate Activism: The Struggle for Sexual Rights in Post-revolutionary Nicaragua, a book on how sexual rights activists have created new national models of sexual subjectivity and rights.
During our conversation, we discussed cultural differences that I should prepare myself for. Dr. Howe said that though Nicaragua is a machismo country with men having the license to do many things that are not egalitarian, as a foreigner I would generally be respected in a gender-neutral manner. That being said, she emphasized that I should always be vigilant and careful about not leaving my host family’s home late at night without a group of both men and women. She recommended that I bring a house-warming gift for the mother of my host family on my first day, as this act would be appreciated and looked upon fondly. In addition, she suggested that for my despedida, I should invite my family out to a restaurant for pizza and coke. She said that eating at restaurants is generally reserved only for special occasions for most Nicaraguan families, and that despedidas or good-bye parties are important to them. In regards to daily life, she said that I should be prepared for extended amounts of family time and relaxed attitudes about time and appointments. Though she mainly worked in Jinotepe and San Marcos, she visited Masaya and explained some its cultural traditions.
To prepare myself specifically for my public health project focused on female sexual and reproductive health, she highly recommended that be up-to-date about the Zika virus before and during my trip. She said that though it is a dangerous time to be traveling to Nicaragua, this would be a truly unique experience to see firsthand how Nicaragua is responding to this public health threat. She encouraged me to talk to people about this and ask people about what they believe to be solutions for this to be – mosquito spraying or eliminating standing water to rid of breeding grounds? – , and furthermore where they believe responsibility should lie – outside organizations, national/local government, individual families?
To conclude our interview, she gave me some general advice to attempt to develop community connections by making the effort to reach out to people and visiting other organizations to learn from them. She recommended that if I try to make myself of service to any organization, they would be willing to let me work with them. Dr. Howe also left me with a short list of news sources that I should read before and during my trip to be able to be conversant with community members about current national happenings. This list included La Prensa (national news source), Envío (academic Nicaraguan articles), and La Boletina (Nicaraguan feminist magazine). I ultimately found all of her personal reflection and specific suggestions to be very useful, and plan to follow her aforementioned advice and read articles on her recommended news sites to prepare myself a richer cultural immersion experience and a more meaningful health post internship.
IV. Community Connection:
The Baylor College of Medicine has a Teen Health Clinic that offers comprehensive reproductive health and family planning care at free or low-cost for both females and males ages 13-25 through a network of nine clinics throughout Houston. The clinics specifically serve neighborhoods that are well known for high infant mortality, sexually transmitted infections, and/or teen pregnancy. The clinic also pursues several community outreach programs and academic research on topics including adolescent high-risk sexual behaviors, young fathers and male development programs, ethnicity and reproductive health, social determinants of health, and HIV/AIDS risk reduction.
Specific medical services that the clinic provides includes immunizations, annual gynecological check-ups for girls who are sexually active, STD tests, and birth control methods and counseling. Beyond these services, staff members pursue several outreach programs including: school-based clinic interventions for first generation immigrants in select Texas high schools (primary care, early pregnancy detection, prenatal care referrals), mentorship programs for young mothers, a scholarship program for young fathers, education outreach to adolescents in lower teen pregnancy, infant mortality, and STDS in high risk areas of poverty in Houston.
I predict that many of the services offered by the Baylor Teen Health Clinic will be similar to the community health center I will be working at in Masaya, Nicaragua. There are pockets in Houston with incidence of disease that are similar to the socioeconomically disadvantaged population of Masaya, Nicaragua. However, there will be differences. From what I have head from previous Loewenstern fellows and my site coordinator from Nicaragua is that the local community health center in Masaya is busy and greatly strained for resources. The Baylor Teen Health Clinic is based in the largest medical center in the world and is connected to several advanced medical institutions. In terms of resources, I predict that there will be a significant gap. The Masaya medical center is also significantly understaffed, and these low doctor-to-patient ratios may translate to less time available to pursue meaningful outreach initiatives.
Another differing aspect between the two is that the Baylor Teen Health Clinic pursues several male-oriented sexual health education and counseling services while I predict that the equivalent of these services in Nicaragua almost solely cater towards women. Because of the machismo attitude that Dr. Cymene Howe brought up during our conversation, I do not think that discussing contraceptives and hygienic and safe sexual practices with men is common.
When I return from the United States, it would be wonderful if I could volunteer at this teen health clinic or another local women’s health clinic to look at varying styles of approach and implementation in different cultural, social and political contexts to broaden my perspective on how to pursue sustainable solutions.
V. Reflection:
Last May I traveled with Rice’s Global Medical Brigades Chapter to rural Jinotega, Nicaragua to help implement a mobile medical clinic and a public health hygiene station construction project in a small community. My experience during this trip was the primary motivation for me to apply for a Loewenstern program experience in Nicaragua for the summer of 2016. Through my interactions with the community members in Jinotega, I learned how their lack of access to healthcare and preventative care education due to their geographic isolation influenced their medical conditions. More specifically, I was exposed to an overwhelmingly high frequency of teenage pregnancies and conditions such as urinary tract infections, consistent vaginal bleeding, and renal infection amongst the young female patients I encountered during our mobile clinic. I saw the pressing need for sexual reproduction and proper hygiene education for female adolescents. This ultimately influenced me to apply for the fellowship to support an internship with Foundations for Sustainable Development at a public health center in an urban health center in Ciudad Sandino that pursues frequent health education outreach programs for the socioeconomically disadvantaged citizens of the community and surrounding rural areas.
As an intern there, I hope to explore these gender-specific issues prevalent in both rural and urban settings in Nicaragua more in depth. Additionally, I hope to learn more about the socialized healthcare system of Nicaragua, which I have heard has a huge focus on preventative care. Through pursuing my own project there, I hope to learn much about effective public health outreach from those around me. As a pre-medical student interested in women’s health and holistic care with a focus on prevention and continued care, I am interested in comparing my experiences working in a community health center in Nicaragua with my experiences interning and volunteering in centers here in the Texas Medical Center. Exposure to different types of contexts, focuses and implementations of health care will definitely change my perspective on delivery of effective medical care. This broadened perspective will hopefully allow me to approach and develop solutions for problems in healthcare delivery here in the U.S. in a unique manner in my future career.
I additionally am interested in pursuing this fellowship to gain experience connecting and immersing myself in a community different than the towns I have been raised in the United States. I predict the most valuable component of my trip will be my interactions with the community members I will meet. As a young student, I hope to challenge myself with the task of thriving in a completely different context than what I am used to. This experience will test my boundaries and will hopefully contribute to my personal development and overall understanding of my capabilities. As an aspiring healthcare provider, I desire to challenge myself with developing meaningful connections with an international community. I personally believe that the ability to empathize and understand different populations is important to be a physician as well as a worldly citizen in general. This trip will allow me to hone on this ability.
This fellowship will provide me the unique opportunity to immerse myself into a community much different than those I have grown up in and expand my worldview. I am excited and ready to confront the challenges that this fellowship entails and am certain I will learn much about the Nicaraguan people and myself from this experience.
VI. Appendix:
References
Capacitarán a 500 bachilleres en salud y a 700 parteras. (2016, January 6). El Nuevo Diario. Retrieved from http://www.elnuevodiario.com.ni/nacionales/381419-capacitaran-500-bachilleres-salud-700-parteras/
Child and Maternal Health Issues in Nicaragua. (n.d.). Foundations for Sustainable Development. Retrieved from http://www.fsdinternational.org/country/nicaragua/healthissues
Demographics of Nicaragua (n.d.) Retrieved from http://www.nicaragua.com/demographics/
Empresar de hotel Hyatt muestra interés en seguir invertiendo en Nicaragua. (2016, January 29). El Economista. Retrieved from http://www.eleconomista.net/2016/01/29/empresario-de-hotel-hyatt-muestra-interes-en-seguir-invirtiendo-en-nicaragua
Gordillo-Tobar, A., Beneitez, G., Ortega J., Waters W., Bravo, E. (n.d.) Adolescent Sexual and Reproductive Health and Rights in Nicaragua: An Analysis Using a Sexual and reproductive Health Framework and Human Rights. World Bank Group – Health, Nutrition and Population. Retrieved from http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2014/12/12/000333037_20141212013101/Rendered/PDF/930930BRI0Box300Rights0in0NICARAGUA.pdf
Lempiainen, M. (2013, March 15). Let’s talk about sex in Nicaragua. Pass Blue. Retrieved from http://passblue.com/2013/03/15/lets-talk-about-sex-in-nicaragua/
Lion, K., Prata, N., Stewart, C. (2009, June). Adolescent Childbearing in Nicaragua: A Quantitative Assessment of Associated Factors. International Perspectives on Sexual and Reproductive Health. Retrieved from https://www.guttmacher.org/pubs/journals/3509109.html
Ma, E. (2016, February 15). Nicaragua’s Construction Sector Expected to Improve Through 2016 and Beyond. Latin One. Retrieved from http://www.latinone.com/articles/32661/20160215/nicaragua-s-construction-sector-expected-improve-through-2016-beyond.htm
Nicaragua. (n.d.). Retrieved from http://www.infoplease.com/country/nicaragua.html?pageno=5
Nicaragua. (2013, April 11). Pan American Health Organization/ WHO. Retrieved from http://www.paho.org/saludenlasamericas/index.php?option=com_docman&task=doc_view&gid=140&Itemid
Nicaragua acumula 70 casos positivos de Zika. (2016, February 17). El Nuevo Diario. Retrieved from http://www.elnuevodiario.com.ni/nacionales/385330-nicaragua-acumula-70-casos-positivos-zika/
Political History of Nicaragua (n.d.) Stanford University. Retrieved from http://web.stanford.edu/group/arts/nicaragua/discovery_eng/history/
Seelke, C. (2008, March 17). Nicaragua: Political Situation and U.S. Relations. CRS Report for Congress. Retrieved from https://www.fas.org/sgp/crs/row/RS22836.pdf
Photograph References
Preidt, R. (2016, January 27). CDC Broadens Zika Virus Travel Alert for Pregnant Women. Retrieved from http://www.usnews.com/dims4/USNEWS/eefadd1/2147483647/thumbnail/652×431%3E/quality/85/?url=%2Fcmsmedia%2F36%2Fbe97f9e5c51c429dd2f6d518bd7b52%2Fmedia%3A12cc993fff6242ffb273fcb77b04d111ZikaVirusUSWarning.JPEG
(n.d.) Retrieved from https://www.alexanderroberts.com/getmedia/7889d2cf-9c7c-48e8-ae38-fb299d1a1435/14-Nicaragua_MainPic.jpg.aspx?width=940
(n.d) Retrieved from http://cdn1.bostonmagazine.com/wp-content/uploads/2014/03/noambulance.jpg
(n.d.) Retrieved from http://www.ketzal.com.gt/images/proyectos/M1.jpg
(n.d.) Retrieved from http://www.mdgfund.org/sites/default/files/images/Nicaragua%20girls%20dancing.jpg
(n.d.) Retrieved from https://www.planusa.org/stuff/contentmgr/files/1/2dbff34dd445aa02f56d61333f7ff0d2/image/sexhealth-nicaragua-2-h.jpg
(n.d.) Retrieved from http://www.retirenicaragua.com/wp-content/uploads/2014/06/Mukul-2.jpg
(n.d.) Retrieved from http://www.scidev.net/filemanager/root/site_assets/maps/Nicaragua-canal.jpg
(n.d.) Retrieved from http://thestudyacademy.ca/wp-content/uploads/2014/01/nicaragua.jpg