““Children's growth up to age five is influenced by Children's growth up to age five is influenced by nutrition, environment and health care, nutrition, environment and health care,

rather than by rather than by genetics or ethnicity.”genetics or ethnicity.”

Factors affecting HealthFactors affecting HealthDiseasesDiseases

In 2002, nearly 11 million children died before In 2002, nearly 11 million children died before reaching their fifth birthday – 98% of these reaching their fifth birthday – 98% of these deaths were in developing countries.deaths were in developing countries.

2006 World Health Organization2006 World Health Organization

World Health Organization data 2001 (from Global Health Council http://www.globalhealth.org)

Leading Causes of Death in Children Under 5 years of age

Perinatal (22%)Perinatal (22%)

All other causes All other causes (29%)(29%)

HIV / AIDS HIV / AIDS (4%)(4%)Diarrhea Diarrhea

(12%)(12%)

Measles (5%)

Malaria Malaria (8%)(8%)

Pneumonia Pneumonia (20%)(20%)

MalnutritionMalnutritionunderlying factor underlying factor

(60%)(60%)

Factors affecting HealthFactors affecting HealthPoverty and Environment Poverty and Environment

Poverty, social exclusion, poor housing and Poverty, social exclusion, poor housing and poor health systems are among the main social poor health systems are among the main social causes of ill health.causes of ill health.

20062006 World Health Organization- World Health Organization- Commission on Social Determinants of Health

1.1 BILLION PEOPLE TRY TO LIVE ON LESS THAN $1 PER DAY (WORLD BANK)

Zimbabwemother and

child

(The Associated Press File photograph; article by B. Willis, Books and Authors, Edmonton Journal May 1, 2005)

(World Bank group http://www.worldbank.org/data/maps/images/GNIpercapita.jpg)

Gross National Income (GNI) per capita, 2003

NicaraguaCountry profile

Nicaragua, NicaraguitaNicaragua, Nicaraguita

MANAGUAMANAGUA

Home for the only Children’s Hospital of the Nation

Hi!

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.

The Tyscapa Lagoon

LEONLEON

Colonial City, where The cathedral is Colonial City, where The cathedral is locatedlocated

Full of Wonderful, hard working, simple Full of Wonderful, hard working, simple people…people…

……Legends, traditions… Legends, traditions… ...and Beauty....and Beauty.

Major Traumas that Major Traumas that affect Children’s Healthaffect Children’s Health

POVERTYPOVERTY WARWAR MALNUTRITIONMALNUTRITION NATURAL DISASTERSNATURAL DISASTERS

HistoryHistory18211524

XIX century

Somoza 1936-1979

Sandinistas 1979-1990

1990-1996

Arnoldo Aleman’s embezzlement

Enrique Bolaños

2001 - 2006

General SituationGeneral Situation

Area: 130,244 km2 (Area: 130,244 km2 (smaller than the smaller than the state of FLstate of FL))

Population: 5,710,670, 56.4% urbanPopulation: 5,710,670, 56.4% urban Life expectancy at birth: 68.4Life expectancy at birth: 68.4 Birth rate: 35.3/1000Birth rate: 35.3/1000 Literacy: 67.5%Literacy: 67.5%

Economy overviewEconomy overview

One of the hemisphere’s poorest countriesOne of the hemisphere’s poorest countries 118118thth in the Human Development Index in the Human Development Index 50.3% of citizens below poverty line, 25% 50.3% of citizens below poverty line, 25%

extreme povertyextreme poverty 20% of Nicaragua’s children malnourished20% of Nicaragua’s children malnourished GDP growth: 3.5% (Public debt GDP growth: 3.5% (Public debt

100.3%GDP)100.3%GDP) Employment/underemployment: 54% Employment/underemployment: 54%

unemployed unemployed 56% urban gainfully employed less than 56% urban gainfully employed less than

$9.20/month (basic basket US$13.3)$9.20/month (basic basket US$13.3)

Natural DisastersNatural Disasters1972 Managua 1972 Managua

EarthquakeEarthquake

Last earthquake: Masaya, July of 2000.

Hurricane Mitch, 1998Hurricane 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

Natural Disasters

Structural Crisis

EconomicAdjustment Measures

Post - War

Political instability

THE EFFECT OF TRAUMA

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).

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):4-25). In a study done in 1991, 62% of men and 91% of

women ex-refugees 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).

Malnutrition, a Global TraumaChild with Spina Bifida and

Hydrocephalus (Folic acid deficiency during pregnancy)

High Prevalence of Prematurity

Child with Myelomeningocele (Folic acid deficiency during pregnancy)

Protein, Calories, Vitamins deficiencies

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 Feb-Apr;10(1-2):51-8).

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).

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.

Health Situation in Health Situation in NicaraguaNicaragua

Major problems include: Inappropriate services for adolescents, Inappropriate services for adolescents,

elderly, disabled, and adults.elderly, disabled, and adults. Focus in health treatment rather than Focus in health treatment rather than

prevention. Preventive medicine is prevention. Preventive medicine is underdeveloped.underdeveloped.

Child psychiatry healthcare services are Child psychiatry healthcare services are very limited nationwide.very limited nationwide.

Health Situation in Health Situation in NicaraguaNicaragua

Life expectancy (years) 68.8

Fertility rate (births per woman) 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) 0.2

Source: World Development Indicators database, April 2004

Specific Health TrendsSpecific Health Trends

Children 0-4: IMR has decreased Children 0-4: IMR has decreased from 45 to 30 (1997-2003)from 45 to 30 (1997-2003) Causes: Pneumonia, diarrhea, Causes: Pneumonia, diarrhea,

gastroenteritis, and transport accidents.gastroenteritis, and transport accidents. Schoolchildren (5-9): accidents, Schoolchildren (5-9): accidents,

pneumonia, drowning, exposure to pneumonia, drowning, exposure to unknown factorsunknown factors

Specific Health TrendsSpecific Health Trends

Adolescents (10-19y): Adolescents (10-19y): FR 152/1000, 3:10 births involved teenage FR 152/1000, 3:10 births involved teenage

mothers. mothers. Deaths: natural disasters, pesticide Deaths: natural disasters, pesticide

poisoning (30%), accidents. poisoning (30%), accidents. Maternal Mortality: 102-133/100,000Maternal Mortality: 102-133/100,000

Hemorrhages by placenta retention, pregnancy Hemorrhages by placenta retention, pregnancy induced hypertension, sepsis, rupture of the induced hypertension, sepsis, rupture of the uterus, and abortions.uterus, and abortions.

Family planning service coverage: 21%Family planning service coverage: 21%

Specific Health TrendsSpecific Health Trends

Elderly: 4.7% of the populationElderly: 4.7% of the population Disabled: 12.1%Disabled: 12.1%

Visual 63.9%, hearing 9.2%Visual 63.9%, hearing 9.2% Birth 10%, disease 29%, war 3%, and Birth 10%, disease 29%, war 3%, and

accidents 12%.accidents 12%. Workers: Workers:

24,000 children 10-14 informal sector, 6000 24,000 children 10-14 informal sector, 6000 formal sector. formal sector.

90-100% farmers exposed to some type of 90-100% farmers exposed to some type of pesticide.pesticide.

Specific Health ProblemsSpecific Health Problems Mental HealthMental Health Vector borne diseases: malaria, dengue, Chagas’Vector borne diseases: malaria, dengue, Chagas’ Diseases preventable by immunization Diseases preventable by immunization

(Pneumococcal, Meningococcal, Varicella nor (Pneumococcal, Meningococcal, Varicella nor Hep. A vaccines are available)Hep. A vaccines are available)

Intestinal infectious diseasesIntestinal infectious diseases Chronic communicable diseasesChronic communicable diseases Acute respiratory infectionsAcute respiratory infections Zoonoses: rabiesZoonoses: rabies Nutritional and metabolic diseasesNutritional and metabolic diseases Circulatory systemCirculatory system Accidents and violenceAccidents and violence Oral healthOral health

Response of the Response of the Health SystemHealth System

Health SystemHealth System

““The deterioration in the country’s health, The deterioration in the country’s health, education and nutrition status is directly related education and nutrition status is directly related to the unequal distribution of resources, lack of to the unequal distribution of resources, lack of

access to basic services, and the economic crisis” access to basic services, and the economic crisis”

(Human Development Report 2002)(Human Development Report 2002)

Structure of the systemStructure of the system

National Health Policy: modernizing National Health Policy: modernizing the health sector and social security the health sector and social security system, strengthening the Ministry of system, strengthening the Ministry of Health, improving hospital care, and Health, improving hospital care, and formulating new strategies.formulating new strategies.

Potential coverage of 3 million Potential coverage of 3 million people.people.

Primary and secondary care.Primary and secondary care. MINSA is the regulatory institution.MINSA is the regulatory institution.

Structure of the systemStructure of the system

Ministry of Health, with 996 health Ministry of Health, with 996 health care facilities (48.3% in the Pacific care facilities (48.3% in the Pacific coast area). coast area).

Private: 8 hospitals each with 400 Private: 8 hospitals each with 400 beds; 200 outpatients clinics.beds; 200 outpatients clinics.

Insurance Managed Companies have Insurance Managed Companies have begun prepaid plans to expand their begun prepaid plans to expand their service.service.

Organization of the Organization of the systemsystem

Ministry of Health

Public (60%) Private (20%) SSI (10%) NGO (10%)

Hospitals

Health centers

Health posts

Community Promotor

Hospitals (8)Medical and dental

Clinics, Labs, imaging centers

Insurance Management

Companies

Human ResourcesHuman Resources

23,285 health care workers (32% Gov, 23,285 health care workers (32% Gov, 47.4% primary, 52% secondary care)47.4% primary, 52% secondary care)

5,656 general practitioners, 950 5,656 general practitioners, 950 specialist, 323 professional nurses, 974 specialist, 323 professional nurses, 974 dentist, 1042 pharmacists, 56 lab tech, dentist, 1042 pharmacists, 56 lab tech, 21 radiologist. 21 radiologist.

Nursing personnel 1538 (62% secondary, Nursing personnel 1538 (62% secondary, 1/3 in Managua). Primary care with 52% 1/3 in Managua). Primary care with 52% auxiliary personnel.auxiliary personnel.

Health expenditure and Health expenditure and financingfinancing

Resources: public sector 41.5%, private Resources: public sector 41.5%, private 44.8%, external cooperation 13.7%.44.8%, external cooperation 13.7%.

Per capita health spending: US$45.1Per capita health spending: US$45.1 Government allocation is 3.2% of GDP Government allocation is 3.2% of GDP

(9.5% general budget). The smallest in (9.5% general budget). The smallest in Central America.Central America.

International assistance 1.3% GDP (25.6% International assistance 1.3% GDP (25.6% total budget)total budget)

Household on health: 2.5- 2.8% of GDPHousehold on health: 2.5- 2.8% of GDP

Public Health SystemPublic Health System

Potable water: urban 89%, and rural Potable water: urban 89%, and rural 33%33% Samples collected: 4% 50 Samples collected: 4% 50

coliform/100mlcoliform/100ml Inadequate excreta disposal: 21% Inadequate excreta disposal: 21%

(rural)(rural) Urban: 65% solid waste not subject Urban: 65% solid waste not subject

to proper disposal.to proper disposal.

International policies and International policies and its impactits impact

IMFExternal debt

100.3 of GDP

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

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

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)

Health care system from the Health care system from the perspective of core values and perspective of core values and

social justice social justice

““That the country counts with an That the country counts with an institutional environment that institutional environment that assures justice, transparency in assures justice, transparency in public affairs and democracy.” public affairs and democracy.” (PNUD Survey, July 2002)(PNUD Survey, July 2002)

Inequities in healthInequities in health

Incidence of diseases and accidents higher Incidence of diseases and accidents higher among: among: Low income level.Low income level. Women of all groups of age and income (50 years Women of all groups of age and income (50 years

old highly vulnerable). High maternal mortality.old highly vulnerable). High maternal mortality. Rural areas, related to income level.Rural areas, related to income level. Respiratory diseases first cause of death children Respiratory diseases first cause of death children

under 5 years old (preventable diseases). Related under 5 years old (preventable diseases). Related to income level.to income level.

Diarrheic diseases among children under 5 are Diarrheic diseases among children under 5 are higher in rural areas.higher in rural areas.

(National Household Survey about levels of life, 1998.)

Inequities in healthInequities in health Women declare more illness and receive more Women declare more illness and receive more

care than men. Among younger than 20, men care than men. Among younger than 20, men receive more care.receive more care.

Care coverage positively correlated to the income Care coverage positively correlated to the income level.level.

Distance and time from the house to health Distance and time from the house to health center are markedly higher in rural areas.center are markedly higher in rural areas.

Institutional delivery lower in rural areas, and Institutional delivery lower in rural areas, and related to the income level.related to the income level.(National Household Survey about levels

of life, 1998.)

Inequities in healthInequities in health 1990 to 2005: 1990 to 2005:

Expenditure on education from 3.4 to 3.1 of GDPExpenditure on education from 3.4 to 3.1 of GDP Expenditure on health 3.9 to 3.2Expenditure on health 3.9 to 3.2

Rural areas:Rural areas: Poverty (50.3%), extreme poverty (25%), children Poverty (50.3%), extreme poverty (25%), children

malnourished (20%), unemployment. malnourished (20%), unemployment. Deforestation, water pollution.Deforestation, water pollution.

Children under weight 10%, under height Children under weight 10%, under height 20%. (1:3)20%. (1:3)

LBW 12%.LBW 12%.(Human development report, 2005)

Inequities in healthInequities in health

(Human development report 2005)

SurveSurveyy

yearyear

Births Births attended by attended by skilled skilled personnelpersonnel

One-year-olds One-year-olds fully fully

immunizedimmunized

Children Children under heightunder height

For age (% For age (% under age 5)under age 5)

IMRIMR

(per 1000 live (per 1000 live births)births)

Under-five Under-five mortality ratemortality rate

PoorePoorestst

20%20%

RicheRichestst

20%20%

PoorePoorestst

20%20%

RicheRichestst

20%20%

PoorePoorestst

20%20%

RicheRichestst

20%20%

PoorePoorestst

20%20%

RicheRichestst

20%20%

PoorePoorestst

20%20%

RicheRichestst

20%20%

20020011

77.577.5 99.99.33

63.663.6 7171 22.422.4 4.14.1 49.649.6 16.316.3 64.364.3 19.219.2

Core Values of the Core Values of the Government Health SystemGovernment Health System

Tendency of locating the development in the Tendency of locating the development in the capital.capital.

Preferential decision according to external Preferential decision according to external policies.policies.

Healthcare services focus on mothers and Healthcare services focus on mothers and children under age 5. children under age 5.

Inappropriate services for adolescents, elderly, Inappropriate services for adolescents, elderly, disabled, and adults.disabled, and adults.

Inappropriate mental health services.Inappropriate mental health services.

Core Values of the Core Values of the Government Health SystemGovernment Health System

Focus in Treatment rather than Prevention. Focus in Treatment rather than Prevention. Preventive medicine is underdeveloped. Preventive medicine is underdeveloped.

No appreciation for the healthcare workforce No appreciation for the healthcare workforce and the importance of education.and the importance of education.

Corruption is still a major threat.Corruption is still a major threat.

What has to be done:What has to be done: Improve social conditions of the poorest.Improve social conditions of the poorest. Eliminate health care inequalityEliminate health care inequality Preventive Medicine ImprovementPreventive Medicine Improvement Improve Mental Health Services for Children and Improve Mental Health Services for Children and

adults. adults. Incorporate public mental health approaches including Incorporate public mental health approaches including

systematic screening and trauma/grief-focused systematic screening and trauma/grief-focused interventions within a comprehensive disaster interventions within a comprehensive disaster recovery program.recovery program.

Programs of reduction of illiteracyPrograms of reduction of illiteracy Sustainable use of natural resourcesSustainable use of natural resources Increase Employment and salariesIncrease Employment and salaries National infrastructure developmentNational infrastructure development

WHAT CAN WE DO?WHAT CAN WE DO?

Make a Make a difference…difference…

One child at a timeOne child at a time

Then, millions at a time…

Discover, Educate, Care, Lead

“A small group of thoughtful, committed citizens can change

the world. Indeed, it’s the only thing that ever has.” Margaret Mead

By Imelda Medina, M.D.By Imelda Medina, M.D.

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