1. “Children's growth up to age five is influenced by
nutrition, environment and health care,
rather than by
genetics or ethnicity.”

2. Factors affecting Health
Diseases

In 2002, nearly 11 million children died before reaching their
fifth birthday – 98% of these deaths were in developing
countries.
2006 World Health Organization

3. Leading Causes of Death in Children
Under 5 years of age
Perinatal (22%)
Pneumonia
(20%)
Malnutrition
underlying factor
(60%)
All other causes
(29%)
Malaria
(8%)
Measles
(5%)
Diarrhea
(12%)
HIV / AIDS
(4%)
World Health Organization data 2001 (from Global Health Council http://www.globalhealth.org)

4. Factors affecting Health
Poverty and Environment

Poverty, social exclusion, poor housing and poor health
systems are among the main social causes of ill health.
2006 World Health Organization- Commission on Social Determinants of Health

5. 1.1 BILLION PEOPLE
TRY TO LIVE ON
LESS THAN $1 PER
DAY (WORLD BANK)
Zimbabwe
mother and
child
(The Associated Press File photograph; article by B. Willis, Books and Authors, Edmonton Journal May 1, 2005)

6. Gross National Income (GNI) per capita, 2003
(World Bank group http://www.worldbank.org/data/maps/images/GNIpercapita.jpg)

7. Nicaragua
Country profile

8. Nicaragua, Nicaraguita

9. MANAGUA
Home for the only Children’s Hospital of the Nation
La Plaza de la Republica. This is where we can find the
old cathedral, Nicaragua’s National Museum, Managua’s
cultural center and other interesting sites.
Hi!
The Tyscapa Lagoon

10. LEON

Colonial City, where The cathedral is located

…Legends, traditions…

Full of Wonderful, hard working, simple people…
...and Beauty.

11. Major Traumas that affect
Children’s Health




POVERTY
WAR
MALNUTRITION
NATURAL DISASTERS

12. 1524
Sandinistas 1979-1990
History
1821
1990-1996
Somoza 1936-1979
XIX century
Arnoldo Aleman’s
embezzlement
Enrique Bolaños
2001 - 2006

13. General Situation





Area: 130,244 km2 (smaller than the state of FL)
Population: 5,710,670, 56.4% urban
Life expectancy at birth: 68.4
Birth rate: 35.3/1000
Literacy: 67.5%

14. Economy overview
One of the hemisphere’s poorest countries
 118th in the Human Development Index
 50.3% of citizens below poverty line, 25% extreme
poverty
 20% of Nicaragua’s children malnourished
 GDP growth: 3.5% (Public debt 100.3%GDP)
 Employment/underemployment: 54% unemployed

56% urban gainfully employed less than $9.20/month (basic
basket US$13.3)

15. Natural Disasters
1972 Managua Earthquake
Last earthquake: Masaya, July of 2000.

16. Hurricane Mitch, 1998
200,000 inhabitants afflicted,
10,000 people lost their homes,
1,000 people were buried when
an entire slope of a volcano
crashed down on 14 villages,
2,823 people died,
885 reported missing,
49 municipalities severely
damaged

17. Natural
Disasters
Political
instability
Structural Crisis
Post - War
Economic
Adjustment
Measures

18. THE EFFECT OF TRAUMA

19. Hurricane Mitch effect on
Nicaraguan adolescents

Adolescents with extreme objective and subjective hurricane-related traumatic
features of exposure experience severe and chronic posttraumatic stress and
comorbid depressive reactions (Am J Psychiatry 2001; 158: 788-794).

PTSD represents a serious mental health problem after a disaster. Higher
vulnerability is found among illiterate persons, females and those with
previous mental health problems (Soc Psychiatry Psychiatr Epidemiol (2001)
36: 108-114).

20. Effects of Civil War on Mental
Health



Civil war during 1980s lasted about ten years, causing terror.
Military service used to be obligatory starting at later teens.
PTSD found in war wounded ex-combatants (Med War. 1994 Jan-Mar;10(1):425).

In a study done in 1991, 62% of men and 91% of women exrefugees still living in the war zone reported as cases of
psychological disturbance on the General Health Questionnaire.
Somatization was central to the subjective experience and
communication of the distress. Anxiety-based symptomatology
common. 25% of men and 50% of women merited a diagnosis
of PTSD (Med War. 1991 Apr-Jun;7(2):84-99).

21. Malnutrition, a Global Trauma
Child with Spina Bifida and Hydrocephalus
(Folic acid deficiency during pregnancy)
Child with Myelomeningocele (Folic acid
deficiency during pregnancy)
High Prevalence of Prematurity
Protein, Calories, Vitamins deficiencies

22. Nutrition and Mental Health

Evidence from observational studies suggests that there is an
association between n-3 long-chain polyunsaturated fatty acids
and depression (Am J Clin Nutr. 2007 Nov;86(5):1278-85).

There is a strong and consistent association between
eicosapentaenoic acid in serum phospholipids and self-reported
physical well-being (Am J Clin Nutr. 2007 Nov;86(5):1278-85).

A history of attempted suicide is associated with low levels of
antioxidant vitamins and carotenoids (Nutr Neurosci. 2007 FebApr;10(1-2):51-8).

23. Malnutrition and Mental Health

In most societies, mothers are the primary providers of nutrition
and care to young children. This is a demanding task, and poor
physical or mental health in mothers might be expected to have
adverse consequences on their children's health, nutrition and
psychological well-being.

What is the relationship between Maternal Mental Health and
Children Malnutrition and Mental Health? Is this a cycle?

Mothers who report stress, depression, or anxiety symptoms are
at risk for nonresponsive feeding styles (J Nutr. 2008
Apr;138(4):799-805).

24. Conclusions
1.
The post-trauma recovery of the severely affected Nicaraguan
children is vital to the social and economic recovery of a
country ravaged by years of political violence and poverty.
2.
Maternal mental health can affect children’s ultimate
nutritional status.
3.
These are worldwide problems, currently not adequately
addressed in developing countries.

25. Health Situation in Nicaragua

Major problems include:
Inappropriate services for adolescents, elderly,
disabled, and adults.
 Focus in health treatment rather than prevention.
Preventive medicine is underdeveloped.
 Child psychiatry healthcare services are very limited
nationwide.


26. Health Situation in Nicaragua
Life expectancy (years)
Fertility rate (births per woman)
68.8
3.4
Infant mortality rate (per 1,000 live births)
30.0
Under 5 mortality rate (per 1,000 children)
38.0
Child immunization, measles (% of under 12 mos)
93.0
Incidence of tuberculosis (per 100,000 people)
62.7
Tuberculosis cases detected under DOTS (%)
91.2
Prevalence of HIV, total (% of population aged 15-49)
Source: World Development Indicators database, April 2004
0.2

27. Specific Health Trends

Children 0-4: IMR has decreased from 45 to 30
(1997-2003)


Causes: Pneumonia, diarrhea, gastroenteritis, and
transport accidents.
Schoolchildren (5-9): accidents, pneumonia,
drowning, exposure to unknown factors

28. Specific Health Trends

Adolescents (10-19y):
FR 152/1000, 3:10 births involved teenage mothers.
 Deaths: natural disasters, pesticide poisoning (30%),
accidents.


Maternal Mortality: 102-133/100,000


Hemorrhages by placenta retention, pregnancy induced
hypertension, sepsis, rupture of the uterus, and abortions.
Family planning service coverage: 21%

29. Specific Health Trends
Elderly: 4.7% of the population
 Disabled: 12.1%

Visual 63.9%, hearing 9.2%
 Birth 10%, disease 29%, war 3%, and accidents 12%.


Workers:
24,000 children 10-14 informal sector, 6000 formal sector.
 90-100% farmers exposed to some type of pesticide.


30. Specific Health Problems











Mental Health
Vector borne diseases: malaria, dengue, Chagas’
Diseases preventable by immunization (Pneumococcal,
Meningococcal, Varicella nor Hep. A vaccines are available)
Intestinal infectious diseases
Chronic communicable diseases
Acute respiratory infections
Zoonoses: rabies
Nutritional and metabolic diseases
Circulatory system
Accidents and violence
Oral health

31. Response of the
Health System

32. Health System
“The deterioration in the country’s health, education and nutrition
status is directly related to the unequal distribution of resources,
lack of access to basic services, and the economic crisis”
(Human Development Report 2002)

33. Structure of the system




National Health Policy: modernizing the health
sector and social security system, strengthening
the Ministry of Health, improving hospital care,
and formulating new strategies.
Potential coverage of 3 million people.
Primary and secondary care.
MINSA is the regulatory institution.

34. Structure of the system



Ministry of Health, with 996 health care
facilities (48.3% in the Pacific coast area).
Private: 8 hospitals each with 400 beds; 200
outpatients clinics.
Insurance Managed Companies have begun
prepaid plans to expand their service.

35. Organization of the system
Ministry of Health
Public (60%)
Hospitals
Private (20%)
SSI (10%)
Hospitals (8)
Medical and dental
Clinics, Labs,
imaging centers
Insurance
Management
Companies
Health centers
Health posts
Community Promotor
NGO (10%)

36. Human Resources

23,285 health care workers (32% Gov, 47.4%
primary, 52% secondary care)
5,656 general practitioners, 950 specialist, 323
professional nurses, 974 dentist, 1042 pharmacists,
56 lab tech, 21 radiologist.
 Nursing personnel 1538 (62% secondary, 1/3 in
Managua). Primary care with 52% auxiliary
personnel.


37. Health expenditure and financing





Resources: public sector 41.5%, private 44.8%, external
cooperation 13.7%.
Per capita health spending: US$45.1
Government allocation is 3.2% of GDP (9.5% general
budget). The smallest in Central America.
International assistance 1.3% GDP (25.6% total
budget)
Household on health: 2.5- 2.8% of GDP

38. Public Health System

Potable water: urban 89%, and rural 33%



Samples collected: 4% 50 coliform/100ml
Inadequate excreta disposal: 21% (rural)
Urban: 65% solid waste not subject to proper
disposal.

39. International policies and its impact
IMF
External debt
100.3 of GDP
Multilateral
Debt Relief
Initiative 2005
Restrictions: Structural adjustment, no increase salary above the projected inflation rate
-Non-compliance with IMF would jeopardize ongoing aid negotiations
Health budget has
been declining
Doctors per 10,000: 6 to
3.8. Overwork. US$300
monthly salary (40% less
than the rest of Central
America)
Insufficient funds for
provision of basic medical
supplies, repairs for dilapidated
hospitals, subsidies for
essential medicines, and other
20,000 public health care
workers declared an
indefinite nationwide
strike in since November,
2005

40. Health care system from the perspective
of core values and social justice
“That the country counts with an institutional
environment that assures justice, transparency in
public affairs and democracy.” (PNUD Survey,
July 2002)

41. Inequities in health

Incidence of diseases and accidents higher among:





Low income level.
Women of all groups of age and income (50 years old highly
vulnerable). High maternal mortality.
Rural areas, related to income level.
Respiratory diseases first cause of death children under 5
years old (preventable diseases). Related to income level.
Diarrheic diseases among children under 5 are higher in rural
areas.
(National Household Survey about levels of life, 1998.)

42. Inequities in health

Women declare more illness and receive more care than men.
Among younger than 20, men receive more care.

Care coverage positively correlated to the income level.

Distance and time from the house to health center are
markedly higher in rural areas.

Institutional delivery lower in rural areas, and related to the
income level.
(National Household Survey about levels of life, 1998.)

43. Inequities in health

1990 to 2005:



Rural areas:




Expenditure on education from 3.4 to 3.1 of GDP
Expenditure on health 3.9 to 3.2
Poverty (50.3%), extreme poverty (25%), children malnourished
(20%), unemployment.
Deforestation, water pollution.
Children under weight 10%, under height 20%. (1:3)
LBW 12%.
(Human development report, 2005)

44. Inequities in health
Survey
year
One-year-olds fully
immunized
Children under
height
For age (% under
age 5)
IMR
(per 1000 live
births)
Under-five
mortality rate
Poorest
20%
2001
Births attended by
skilled personnel
Richest
20%
Poorest
20%
Richest
20%
Poorest
20%
Richest
20%
Poorest
20%
Richest
20%
Poorest
20%
Richest
20%
77.5
99.3
63.6
71
22.4
4.1
49.6
16.3
64.3
19.2
(Human development report 2005)

45. Core Values of the Government
Health System





Tendency of locating the development in the capital.
Preferential decision according to external policies.
Healthcare services focus on mothers and children under age 5.
Inappropriate services for adolescents, elderly, disabled, and
adults.
Inappropriate mental health services.

46. Core Values of the Government
Health System

Focus in Treatment rather than Prevention. Preventive medicine
is underdeveloped.

No appreciation for the healthcare workforce and the
importance of education.

Corruption is still a major threat.

47. What has to be done:









Improve social conditions of the poorest.
Eliminate health care inequality
Preventive Medicine Improvement
Improve Mental Health Services for Children and adults.
Incorporate public mental health approaches including systematic
screening and trauma/grief-focused interventions within a
comprehensive disaster recovery program.
Programs of reduction of illiteracy
Sustainable use of natural resources
Increase Employment and salaries
National infrastructure development

48. WHAT CAN WE DO?

Make a difference…

One child at a time

49. Then, millions at a time…
Discover, Educate, Care, Lead

50. “A small group of thoughtful, committed
citizens can change
the world.
Indeed, it’s the only thing that ever has.”
Margaret Mead

51. By Imelda Medina, M.D.

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53. References (cont.)



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
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


Goenjian AK, Molina L, Steinberg AM, Fairbanks LA, Alvarez ML, Goenjian HA, Pynoos RS. Posttraumatic stress and depressive reactions among Nicaraguan adolescents
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