El Salvador

Today, most news sources’ headline story was “The Day without Immigrants.” From Los Angeles to New York to my hometown of Milwaukee, thousands marched to protest proposed immigration laws.

NPR’s Marketplace radio show (”One home, Two nations“) has a wonderful portrayal of two friends–Francisco Castro and Luis Molina–and their decision of whether or not to move to the U.S. Francisco decided to make the move and has made his family more affluent. He often sends money back to his hometown of Chinameca, El Salvador. According to the CIA World Factbook, 16.6% of El Salvador’s GDP comes from foreign remittances to residents.

On the other hand, Luis decided that breaking up his family–even temporarily–was too big a risk for him to take. He is educating his children in El Salvador and hoping that his country gives them sufficient opportunities to succeed in the future.

Read the transcript or listen to the report; my summary does not do it justice.

“On ‘Meet the Press’ in October 2004, when Tim Russert, the host, asked Jim DeMint, a South Carolina Republican representative then in the middle of what turned out to be a successful campaign for the U.S. Senate, to explain his position in favor of a total ban on all abortion procedures. DeMint was reluctant to answer Russert’s repeated question: Would you prosecute a woman who had an abortion? DeMint said he thought Congress should outlaw all abortions first and worry about the fallout later. ‘We’ve got to make laws first that protect life,’ he said. ‘How those laws are shaped are going to be a long debate.’

Russert refused to leave the congressman alone. ‘Who would you prosecute?’ he persisted.

Finally DeMint blurted, ‘You know, I can’t come up with all the laws as we’re sitting right here, but the question is, Are we going to protect human life with our laws?’

In El Salvador, the law is clear: the woman is a felon and must be prosecuted.”

This Sunday’s New York Times magazine has an interesting article (”Pro-Life Nation“) on abortion in El Salvador. Many countries such as Chile, Malta, and Colombia outlaw abortion, but El Salvador is one of the few who prosecutes the mother seeking the abortion as a felon. Penalties are stiff in El Salvador:

“…the abortion provider, whether a medical doctor or a back-alley practitioner, faces 6 to 12 years in prison. The woman herself can get 2 to 8 years. Anyone who helps her can get 2 to 5 years. Additionally, judges have ruled that if the fetus was viable, a charge of aggravated homicide can be brought, and the penalty for the woman can be 30 to 50 years in prison.”

Another problem which arises is that physicians in El Salvador have an obligation to both protect doctor-patient confidentiality and to accumulate evidence for the prosecution of an abortion case.

Whichever side you fall on in the debate on abortion, the article is certainly an interesting one.

One of the largest healthcare risks in many countries is war. Between 1980 and 1992, El Salvador experienced a violent civil war between the right-wing military government and the FMLN (Frente Farabundo Mari para la Liberacion Nacional) communist guerrilla forces. The conflict began to boil over in 1977 when armed forces arrived at Universidad Centroamericana and assassinated six Jesuit priests who were defending the rights of the poor. After the assassination, the archbishop Oscar Romero cut off ties with the government and vehemently spoke out against the government’s repressive policies. After tolerating his outspoken behavior for three years, the government decided to end Romero’s advocacy; Romero was assassinated in 1980 and a civil war ensued.

The village where I stayed (Ciudad Romero) was a FMLN stronghold. As the war began, the government attacked and the villagers fled to Honduras. The military of Honduras, however, was friendly with the right-wing Salvadoran government and the community lived for six months surrounded by military personnel from both countries. As the health of the villagers began to deteriorate and food became scarce, the UN and Panama decided to offer the villagers refuge in Panama. The community lived in the Panamanian jungle for eleven years until the peace accords were signed in 1992 and they were allowed to return and re-establish their town in the Usulatan province.

Today there is an uneasy peace, but discord between the two groups is strong. The divide between the right wing ARENA party in power and the left wing FMLN party has led to central government to spend money mostly in the areas which support ARENA. For instance, Ciudad Romero had no health clinic, but the nearby village of Isla de Mendez–in which a majority of the population still supports the right wing cause–does have a health clinic paid for by the central government.

El Salvador is a turbulent country, where earthquakes, volcanoes, hurricanes and war are a constant threat. One can only hope that this fragile peace will remain and that the quality of life for the Salvadorans will improve in the future.

I would like to thank all the Salvadorans who showed me such gracious hospitality while I was visiting their country. In particular: a Leonides, por compartir sus conocimientos; a Christino por su amable sonrisa y por cantarnos sus rancheros; a Lorena por su belleza escondida; a Carlos y Maribel por prepararnos la comida bien rica; a Jenni y Katia por su inocencia, y a Carlitos, el gran pintor, por el dibujo que me diste. Gracias.

In El Salvador, one finds two parallel health care system.  The first uses state-of-the-art technology, qualified doctors, and physician spend ample time with patients.  The second employs third world technology, treats severe illnesses superficially, and doctors are overworked.  Which of these systems is run by the government?  Which of these systems serves the poor?

As you probably guessed, the first healthcare system described above involves doctors in private practice with a fee for service (FFS) provider payment system.  Using the private physician and medical facilities is expensive; only the wealthy can afford these procedures.  The poor are relegated to using the free government hospitals and clinics.  These facilities do an adequate job of providing immunizations, prenatal care and educational material, but do not have the funds or the staffing to perform surgical procedures which in the U.S. would be considered routine.  Many Salvadorans I spoke with complained that doctors in the public hospitals treat all serious diseases the same: they give patients an aspirin and tell them to grin and bear it since surgery or other complicated procedures are not available.

Also, one notes a distinct difference between urban and rural clinics serving the poor.  Both provide only the most basic of services, however, rural physicians do have more time to spend with patients due to the lower population density.  One physician in the village of Isla de Mendez told me he only saw about 25-30 patients per day and about half of these were educational prenatal visits.  The residents of Isla de Mendez, however, do not have access to medical care on weekends because the physician returns to his home three hours away in the city of San Miguel.  In an urban clinic, patient volume is much higher and wait times of many hours is common, but physicians are available on weekends for emergencies.

The central government also employs promotores, workers who visit villages (such as Ciudad Romero) who do not have a clinic and educate the population about public health risks.  Unfortunately, it seems that the promotores are not very effective since the villagers do not hold these workers in as high esteem as physicians.  Further, since the promotores travel from village to village, they rarely establish a strong bond with the community to make sure that the educational information they impart is implemented.

Plastic bottles strewn on the street, trash fires burning in front of homes, and primitive latrines…El Salvador is pretty much the antithesis of a stereotypically pristine European city. While in the US, we take trash collection for granted–we put our waste into the trash/toilet and it is taken away–in El Salvador waste disposal does not operate as smoothly.

Many residents in rural villages do not have access to trash collection and thus resort to burning their garbage under a pile of leaves. The smoke from burning mounds pollutes the air and the smell is potent. In addition to problems of cigarette smoke and excess dust from dirt streets, the burning of trash has contributed to a high rate of respiratory disease in El Salvador. The burning of garbage made from plastic pollutes the air even more than the typical household refuse. The solution to the problem that one NGO came up with was to have a trash compost area for each house where biodegradable waste could be buried under a layer of dirt and leaves in order to reduce air pollution. The waste would slowly decompose and air pollution—and thus respiratory disease—could be reduced. Paved streets would also reduce pollution from the dust spewed into the air from passing cars and farm animals but this solution is more expensive (although it does have the economic benefit of decreased transportation costs).

Another problem rural El Salvador faces is the disposal of human waste. Since the water level is only 10-15 feet below the ground in the low-lying Bajo Lempa region, allowing residents to defecate into the ground can pollute drinking water, leading to parasitic diseases. One NGO has used raised latrines to solve this problem. The latrines have a concrete box located above ground and below the toilet. Feces fall from the toilet into the chemical lined concrete box in which the chemicals dry the human feces into a solid mass. The feces/chemical mixture can them be removed from the area below the latrine and be used for fertilizer. The cost of one of these raised latrine units is around $600 per unit.

“What are the most significant problems facing El Salvador today?” I asked ‘Chungo’, the nickname of a fifty one year old representative of Ciudad Romero? His response was: 1) clean water, 2) electricity and 3) paved roads.

When visiting a clinic in the village of Isla de Mendez, I asked the resident doctor what single project he would elect to improve the health status of his patients, he stated “Clean water for the residents to drink.”

In El Salvador, like most other developing nations, their most pressing need is that for clean water. CNN reports that over 1.1 billion people do not have access to clean drinking water in the world. The NGO Global Water claims that over 40,000 people die each day from diseases directly related to drinking polluted water.

Fortunately, El Salvador has very good access to water. Rivers are abundant; the water level in the Bajo Lempa region I visited was only about 10-15 feet below the ground. Access to clean water, however, is another story. Many residents were ill with parasitic infections and a fellow volunteer received a rash after wading into a polluted bay on the Pacific coast.

Since El Salvador is not water poor, the solution to its health problem is simply to clean the water which already exists. In the largest city, San Salvador, water is provided by the government in a centralized manner, much as it is in the United States. The small village of Ciudad Romero employed wells from which its residents received running water.

In other rural areas, however, centralized water provision may be too costly to justify for areas which are not densely populated. There were two solutions the villagers used: chlorine tablets or individual filtration systems. The clinic I visited gave chlorine tablets to some residents without clean water, but I was not able to discern if these were free. Most residents resisted using the tablets since they claimed that the water tasted bad. Fifty five of about 350 families in Isla de Mendez had a filtration system in which bath and laundry water passed through different stone basins, with each basin filtering out a different kind of impurity. In the last stage of the treatment, the water passed through stone filters. The system seemed to be working well, but the local NGO had to educate the population on its use since the device had to be cleaned every three days. Without the education component, the funds invested in the filtration system could have gone down the drain.

This week, I will be doing a five part report on what I have learned from my eight-day community service trip to El Salvador. The trip was organized by the non-profit AJWS and was led by employees of the Salvadoran non-profits La Coordinadora del Bajo Lempa and the Foundation for Self Sufficiency in Central America (FSSCA). The majority of the time I was located in the rural town of Ciudad Romero in the Usulatan department, but I did visit other towns as well as the capital of San Salvador. In the course of the week, I was able to speak with a variety individuals: a doctor at a local clinic, community leaders from the villages of Ciudad Romero and Isla de Mendez, a student from the Universidad Centroamericana, workers at various non-profits, and many Salvadoran families.

The major healthcare issues for rural Salvadorans for which they seek medical treatment are the following:

• Childbirth
• Fever
• Dehydration
• Diarrhea
• Injuries from Accidents (eg: lacerations, broken bones, etc.)
• Parasites
• Asthma Attacks

Basic immunizations are widely available to all citizens free of charge. Access to doctors in urban areas is relatively easy, but expect to spend a large amount of time in the waiting room. For rural citizens, one may have to travel up to an hour to reach a nearby clinic and hospitals are often more than an hour away due to the poor state of most roads. For instance, to drive from Ciudad Romero to the nearest hospital took a little over two hours. In a larger country, the problem of transportation from rural areas to hospitals would be even more prevalent than in the case of the small country of El Salvador.

Below is the Schedule for the rest of the week’s posts:

• Tuesday: (Part II) Water
• Wednesday: (Part III) Sanitation
• Thursday: (Part IV) The Salvadoran Healthcare System
• Friday: (Part V) Government, History, and Service Procurement

For the next week I will be headed to Ciudad Romero in the department of Usulatan in El Salvador to assist the local population through their NGO La Coordinadora del Bajo Lempa (Lempa is for the Lempa river which runs near the town). Directed by La Coordinadora, I will work on social justice projects such as planting, digging ditches for the laying of water lines and other tasks.

El Salvador is a poor, densely populated country with 6.7 million inhabitants. Life expectancy is 71.2 years and infant mortality is 25.1 deaths/1,000 live births (compared to 77.7 and 6.5 respectively in the United States). Fortunately, AIDS is not a problem in this country; only 0.7% of the population is infected. Although El Salvador is small and 36.1% of the population lives below the poverty line, it does have the third largest economy in Central America and a GDP per capita figure of $5,100. Over 16% of GDP, however, comes from remittances from Salvadorans living abroad. Politics in El Salvador is rarely stable, whether that be due to military dictatorships (such as Oscar Osorio and Fidel Sanchez Hernandez in the mid 1900s) or revolutionary Marxists groups (such as the Frente Farabundo Martí para la Liberación Nacional). In 1980-1992 civil war, rightist death squads created havoc for the local populations who would oppose their policies. Since the resolution of the war, however, El Salvador has been a peaceful place and the FMLN has even reconstituted itself as a legitimate political party.
For all those in cold weather cities, I’m sorry to say that Weather.com’s ten day forecast has highs between 88 and 95 degrees every day.

My posts will resume on April 3rd. Hasta luego.

Source for Statistics on El Salvador: CIA World Factbook