By Madysen Kovac and Sonia Ros
Day 1: Next Stop, Nicaragua
Our adventure was set to start at 17:50, but of course, you know airports. Delays, gate changes, and long lines at security are commonplace. You name it, it happened to us. Hour waits at security, the gate was changed 3 times, and the departure time was pushed back almost three hours. Luckily, we were all just able to laugh it off and move on. At one of the first trip meetings we had, we were told that being flexible was important, as things often never went as planned during these trips.
As we finally boarded the plane around 20:30, familiar Emory faces were spread throughout the cabin. The plane ride was a bit bumpy, but we made it to Nicaragua and were cozy in our beds by midnight (side note: Nicaragua is one hour behind Atlanta).
I also wanted to give a quick introduction to some of the leaders involved in the trip with us 14 Emory nursing students. Our leaders from Emory are Gladys Jusino-Leon and Ursula Kelly. Upon arrival in Nicaragua, we meet the leader from Communidad Connect (the organization Emory has partnered with to make the trip possible) named Humberto. Also, we will have Dr. Quintana, who is a native of Nicaragua, to show us around and connect us with the community leaders as well as health clinics.
Day 2: Let the Learning Begin
After a quick breakfast, we piled into our 22-seater van and headed out to the town of Tola. No photo could do justice to some of the beautiful sights along the two-hour journey to Tola. We were incredibly excited to get to the clinic and learn about the healthcare system.
This clinic, the health center of Tola, serves 67 communities, of which only two are urban communities (the rest being rural). Local nurses from Tola put together a presentation to teach us about the healthcare system in Nicaragua. Throughout these 67 communities, there are 11 sectors that have health centers, which is an improvement on the previous 7 health centers.
At each of the 11 health centers, there are usually only 2 nurses and 1 doctor to care for an average of 4,000 patients. The nurses are regulated by the government to see a certain number of patients a month, and the same goes for the doctors. Furthermore, if a patient does not show up for an appointment, the nurses and doctors must go out into the community to follow up with the patient. Already, you can see a barrier to providing healthcare in Nicaragua, a lack of staff. To augment the staff and aid in attempts to reach more of the community, brigadistas are used. Brigadistas are volunteers who are trained by nurses to go into the community and assess their needs and make referrals to hospitals if needed. Furthermore, the brigadistas are equipped with acetaminophen and oral rehydration therapy to assist anyone in the community who is febrile or has diarrhea.
Only recently, in 2009, has their healthcare system become more integrated and holistic, as before most services were fragmented. For example, if a woman came in for an appointment and brought her child, they would only treat the woman. Now, if a woman comes in with her child, they give preventive care to both mother and child. Also with this holistic care, the traditional healers are now included. Only recently has MINSA accepted traditional/natural medicine into practice. After some cultural sensitivity training with the nursing staff, they have come to accept and integrate traditional healers into their practice. Dr. Quintana explained that the doctors and nurses are more willing to accept the practices of natural medicine because it does no harm to the patient at the end of the day. Those who practice natural medicine can treat a variety of things such as stress, the curse of the evil eye, and bone pain with many different methods. Some methods include using plants and herbs, shiatzu, or even tai chi.
The referral system in the country is also quite interesting. First is the level 1 clinic. To get here, you may come as a walk-in or you can be referred to the clinic by a community leader. The more acute are then referred to a level 2 facility, which is generally a hospital, and the most acute are referred to a level 3 facility, which is a hospital in the capitol, Managua.
Another interesting thing about the healthcare system of Nicaragua is that all public services are free to the patients of the community, no matter what level of care they are receiving. Currently, MINSA in Tola is working on reorganizing the 11 sectors and ensuring they are fully staffed and educated. Additionally, they have several growing cities and they are expanding the sectors to accommodate for that. Lastly, they have constantly been collecting data about the health of the communities since 2009 to compile a database of information. To track these, they have created hand drawn maps of each community and marked, with colored tacks, the different ailments and situations they need to keep an eye on. For example, the green pin is for chronic illnesses and the red pin is for those who were pregnant.
Many women in the country are hesitant to go to the hospital to give birth, as they would rather do it more traditionally, as they always have, in their own homes. A few new projects have been implemented to encourage women to come to the hospital for their birth. When women agree to come to the hospital, they can bring any traditional meals they may have eaten at home, they can give birth in the position they feel most comfortable (which may not always be in a bed), and the hospitals allow the husbands to be in the birthing room as well. However, many pregnant women do not live close to a hospital, making hospital births more unrealistic. So, they created la casa materna (which basically just means maternal home; a home for pregnant women). This is a place where women can come just before they give birth to be closer to a hospital when labor begins.
The biggest problems in Nicaragua for pregnant women are preeclampsia and teen pregnancy. As confirmed by Dr. Quintana, most of the teen pregnancy issue is a cultural thing because in Nicaragua it is more acceptable for women to have kids and get married at a younger age. Overall, the biggest problems for health in Nicaragua, in order of most to least severe, are hypertension, diabetes, and kidney disease.
To speak specifically to the nursing aspect of healthcare in Tola, the nurses told us how the nursing shifts used to only be from 8am to 4pm, with no around the clock clinic care. Now, there is 24/7 care at the clinic with the shifts being from 8am to 4pm and 4 pm to 8am on the weekdays. The nurses work 24 hours shifts on the weekends. Whew!
The biggest barriers to nursing care in Nicaragua are related to a lack of understanding by the patients and a lack of medical staff. To attempt to make up for a lack of literacy and understanding, the doctors often draw pictures to explain complex concepts and ensure medications are taken at the proper times. The problem with the lack of medical staff stems from many places. One being that it is expensive to train nurses and doctors, as the government pays for all the training. For this reason, there are limited spaces. Also, there seems to be a cap on the number of doctors and nurses allowed at each healthcare clinic, as most of the clinics have 1-2 doctors and only 3-4 nurses. The newly graduated nurses come out with no job availability because there is no spot until the nurses retire and a job opens.
After the nurses spoke, Dr. Quitana spoke to the culture of Nicaragua, as she herself was born and raised here. She said that there is a strong family aspect in Nicaragua and the people of Nicaragua are strong in the things they believe. They believe they are stronger together. This strong sense of community is important to them and their culture and they see everyone as family. She referred to Nicaragua as a, “big, small town.”
After a long day, we were all ready to shower and relax a bit before dinner. The hotel we were staying at for the night had a beach within 30 seconds of it. Gladys, a trip leaders, urged us to take a quick look. The sun was just starting to set in the cove of Playa Gigante. It was a beautiful and satisfying way to end the day.