Photos and story by David Zentz

In the small community of Guisquiliapa, Nicaragua, Juan “Chico” Francisco Cortez Caseres, 77, sits quietly in his new wheelchair, rotating his shoulders to demonstrate how sore they are. Three months ago a stroke landed him in the hospital. The lack of circulation in his body resulted in brain damage and the amputation of both his legs.

His wheelchair allows him to get around the house, but the dirt roads outside his front door are too bumpy to safely navigate his own neighborhood.

“I used to go out. Right now I can’t. I can flip over,” Chico says.

To keep Caseres alive, his son, Alfonso Cortez Treminio, the household’s sole income earner, spends nearly two-thirds of his $63 monthly income on medicine, using the rest to support the family of eight.

Cases like this are common throughout Carazo, a region in western Nicaragua, the second-poorest nation in the Western hemisphere, an hour southwest of the capital city of Managua. Like much of the nation, a large number of Carazo residents live in poverty and have trouble gaining access to quality health care – preventative and curative. For the 39 percent of Carazo residents living in rural areas, the combination of isolation, poverty, and poor living conditions increase the likelihood that people will suffer from health problems and decrease their odds of receiving proper treatment.

Since the Sandinista era ended in 1990, increasingly privatized health care has taken the place of socialized medicine. For the 10 percent of the population who can afford private clinics, this has meant a boost in quality. Yet, despite recent efforts to meet demands for improvement in compliance with the requirements for debt-forgiveness set forth by the World Bank’s Heavily Indebted Poor Countries, or HIPC, Initiative, few improvements have been realized by the masses.

The residents of the remote Los Encuentros community in southern Carazo know this well. The lack of electricity and running water prevents this community of 2,000 from having a health center. To get to the nearest health post they must travel more than 6 miles by foot or horse, or pay a small fare to take the bus that comes three times daily down the long, deeply riveted dirt road leading to the community. Should a more serious situation arise, they must travel much farther to get to a hospital in either Jinotepe or Managua.

Even in slightly more developed communities, such as Dulce Nombre, which now has running water, electricity and a health center, getting care is difficult. More often than not, the health center is closed. During the three days a week it is supposed to be open, it often remains closed due to frequent strikes by the doctors. If anything happens outside the hours of operation, a patient must wait or find a way to travel up the long, dirt road to the top of the hill – a half-hour truck ride. Without their own transportation, once they get to the top of the hill they must wait for a bus to take them to Jinotepe or Managua.

Once someone gets to the doctor, getting medicine is another story. Public health centers, funded by the Nicaraguan government’s Ministry of Health, only provide basic medications for free. Even when medicines are in stock, penicillin and aspirin are about all that are available. For other ailments, all doctors can do is write a prescription. But unless patients can afford to have them filled, they typically do without.

The ministry gives priority to children, pregnant women and certain chronic conditions, such as asthma and epilepsy. Individuals with epilepsy, for example, can continually receive a one-month supply of medicine at no cost. For some the free medicine is too weak and they must pay to get anything stronger.

Maritzaa Aguirres Perez, 37, who lives with her family in the remote community of Los Fierros, south of Jinotepe, has been an epileptic for 25 years. For her, the free medicine is not enough, and epileptic episodes cause her to fall daily, keeping her housebound.

“It is very sad,” says her brother, Rolando Perez. Every day, he hikes out of the valley to catch a bus to Managua, where he works in agriculture. Earning less than $2 a day, he cannot afford to pay for the proper medicines she needs and support the family.

Overall, the public medical system is underfunded. Specialists and general physicians regularly go on strike to protest their low wages and the lack of supplies available to treat their patients.

“We don’t have any resources,” says Dr. Roberto Vasquez Castillo, an orthopedic surgeon in the Jinotepe hospital who is involved in several small community outreach programs.

In addition, he says the Ministry of Health pressures the centers to perform better and meet higher standards.

“They judge us as [if] we are in the first world,” Castillo says. “But, the equipment is the same as in the states 80 years ago.”

“We don’t always have the best equipment, so we cannot give the right service” says Dr. Novel Molina, the sole physician at the health center in Dulce Nombre. Despite the limitations, he says they try to give the best care possible.

On average, a general physician in Nicaragua will make a basic salary of $150 a month. Nurses make far less. The generally poor compensation medical professionals receive at work has a negative effect on the quality of care. Many doctors, particularly specialists who are only required to work five-hour days, supplement their incomes in other ways, such as being educators or running a private practice.

Despite his Sandinista political leanings, Castillo believes the system is moving in the right direction.

“We realized that people have to pay for what they receive,” he says. If you provide free medicine, people often unnecessarily take the drugs or sell them.

Typically, the only help for both the health centers and the patients comes from external sources. Organizations such as Children’s Network International fund one-week outreach missions, providing services such as vaccinations, prescriptions and eyeglasses to residents of the poorest areas.

Missions are always appreciated, but Castillo notes that they only provide infrequent, temporary fixes.

“What about the other 51 weeks of the year?” he asks.