The International Writers Magazine: Destinations: Nicaragua

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Nicaragua, Nicaragüita A Beach Party and Other Encounters • Roger Smith Salinas Grandes, Northwest Nicaragua My wife, a gastroenterologist, and I are sitting on the upper floor of an open-air beach house, holding Nica libres (Flor de Caña rum and coke), looking out into the tropical Pacific Ocean, and exchanging desultory comments with our hosts, Loreto and Dora Cortés. Dr. Cortés is a prominent surgeon himself and a medical professor at the University Nacional Autónoma de Nicaragua (UNAN) in nearby León. My wife and two other doctors from Oregon have spent the last week helping local doctors perform particularly tricky procedures with the endoscopy equipment they've donated to the León university hospital. The beach party is an entertainment arranged as a thank you.

We arrived to find a dozen of Dr. Cortes' colleagues and their medical school students. But there is a further surprise. Two other groups of doctors are present, one composed of surgeons and another of urologists, both from North Carolina, along with wives and children.

There are perhaps forty people all told, and the Nicaraguans sit in a big group drinking beer or rum and singing folksongs together as one intern plays the guitar. We Norteamericanos chat or walk down to the beach to body surf. At the latter, the Nicas show dismay. The breakers, which would delight any surfer, are very dangerous, they say. People drown there often; they’ve never been in the surf above their waists because of it. But two young gringo surgery residents dive right in. Soon they are slipping in and out of the foaming waves like pallid seals, unmindful of the supposed dangers (one admits later that there was a mild rip tide).

The episode is diverting, and it’s difficult not to take it as emblematic. Here are the Nica doctors, among the nation’s best educated science professionals, dressed as for a cocktail party, casual but natty, staying well away from the beach on the assumption of peril that they’ve never directly tested. The North Americans, dressed to swim, plunge in heedless of the dangers and find a way, typically, to skim the surface in an exhilarating game, riding the waves over and over. Rash North Americans see opportunity; Central Americans, belabored by their history, see hazard.

Yet however suggestive the symbolism, it does not encompass the complex relationship between the peoples of Nicaragua and the United States. That has evolved during a history of intervention, by invitation, to settle political disputes; time after time the invitation backfired on the faction doing the inviting. For centuries, the traditional factions have been the liberals centered in León and the conservatives centered in Grenada, a lovely city of Spanish colonial architecture eighty miles to the south on the north shore of Lake Nicaragua.
In the first instance, the liberals, losing in a 1853 civil war, invited a mercenary from the American South, William Walker, to help. Commanding a force of Southerners, Walker defeated the conservatives, stayed in the country afterwards, and declared himself president, thereby starting civil turmoil of his own. He remained in power only two years before being assassinated.

Then in 1912 at Corinto, twenty miles north of this beach, a battalion of U.S. Marines staged an amphibious landing (unopposed) to support the conservative national government, then under siege from rebels who objected to the rapacious corruption of the president, a strongman supported by U.S. interests in the country. Those interests were primarily fruit plantations; Nicaragua was a banana republic. The rebels were liberals, and the Marines quickly crushed the initial rebellion, which turned into a guerrilla war. It spread and eventually centered on one charismatic leader, General Augusto César Sandino (namesake for the Sandinistas). The Marines fought on for two decades, killed thousands, and left in power the first Somoza, Anastasio, as commander of the national guard in 1936. Soon he made himself president as well and, no matter what party claimed to be in power thereafter, real control of Nicaragua remained in the hands of the Somoza family until 1979.

Then a popular uprising led by the Frente Sandinista de Liberación National (FSLN, or Sandinistas) forced Anastasio’s son (also Anastasio) from power, set up a socialist system, and began to redistribute the land to peasants. The government of the United States, piqued to have a communistic state nearby—one, in fact, openly supported by the Soviet Union—took covert measures, again at the urging of conservatives, many of whom had fled Nicaragua to live in the U.S.. President Ronald Reagan supported anti-Sandinista rebels, called Contras, which included former Somoza national guardsmen and a collection of Miskito Indians, mercenaries, and malcontents. A murderous civil guerilla war ensued that killed more thousands, frustrated the Sandinista reforms, inspired oppression from the Sandinista-controlled military, and finally proved nothing.

The Contras did not win, their efforts degenerating into outright banditry; the Sandinista leadership grew too fond of power and comfort, and the inevitable happened: A majority of Nicaraguans turned against them. They lost the presidency to a centrist bloc candidate in 1990 (and to their credit the Sandinistas stepped down without violence). During all this, the United States was identified with the worst of the political elements, the Contras, and was presumed to control them via the archdemon of Latin America, the Central Intelligence Agency.

Now again, beginning in 2003, conservatives and centrists have been looking to the U.S. for help, albeit in a novel form. Because of the swiftly worsening economy and increasing unemployment, the government of President Enrique Bolaños is anxious to sign a regional trade treaty with the United States. In English it is titled the Central American Free Trade Agreement (CAFTA); in Spanish it is el Tratado de Libre Comercio entre Centroamérica y los Estados Unidos and is popularly known as TLC. But no one expects that there will be any tender loving care involved. Patterned on the North American Free Trade Agreement (NAFTA) between Mexico, Canada, and the U.S., CAFTA is designed to eliminate tariffs (gradually), open borders to trade and investment, and enforce intellectual property rights. That means, at least in potential, that the U.S. will have to drop its quotas and subsidies, and so Nicaragua goods may find a huge new market. Also, U.S. goods would flow more easily into Nicaragua, but more important, U.S. money could pour in as well to buy up or invest in its land and industry, creating jobs and freeing the economy from foreign aid and International Monetary Fund oversight.

Despite such promise, liberals and conservatives alike speak of CAFTA with an undertone of urgency and worry. The basis of the reaction is simple. Nicaraguans know that their country—Central America as a whole, in fact—is a very small place in comparison with the three behemoths to the north, the U.S., Mexico, and Canada. They fear being overwhelmed. Yet the conservatives foresee few alternatives in curing the basic problems of debt and currency liquidity. There is little currency available, either in U.S. dollars (which businesses here readily accept) or the national currency, córdobas. Conservatives point out that it is very difficult to get an affordable loan with which to start a small business because the minimum interest rate is 15 percent. For their part, liberals, especially the Sandinistas, fear that under CAFTA Nicaragua will revert to a banana republic twenty-first century style and lose autonomy. Specifically, they worry that foreigners will soon own the land and facilities, or control them through investments, and Nicas in general will simply provide an exploitable, low-wage labor pool. The middle class and professionals will simply become factotums for foreign interests, principally those in the United States. The current glaring economic inequality would worsen. Moreover, the intellectual property provision of CAFTA would end access to cheap generic and knock-off drugs so that medications would be too expensive for the majority of Nicaraguans to treat the endemic gastrointestinal diseases, malaria, dengue fever, and respiratory diseases. So public health would suffer as well.

These hopes and fears may be moot; there is powerful opposition to CAFTA in the U.S. Congress, and grass roots opposition to the treaty in Central American countries may stymie its application even if it does go into effect. Even should CAFTA fulfill the most optimistic hopes of it proponents, the increased North American presence is likely to be a mixed blessing—or perhaps a mixed curse. The experience of private American medical aid illustrates the point. My wife and her Oregon colleagues are visiting under the auspices of Nicaplast (originally started by plastic surgeons), but it is only one of many such non-governmental organizations. On my first trip to the country, even at the airport I ran across groups of dentists and optometrists; later I met surgeons, internists, and pediatricians, some of whom have been coming at least once a year for three decades. Despite this long and intimate contact, even despite well-established friendships among some North American and Nicaraguan doctors, there remain striking differences in perspective that can cause problems—and it must be kept in mind that these problems involve the least suspicious, most accommodating segment of the country's intelligentsia.

The obvious difference involves money. North American doctors personally earn far more than their Nicaraguan counterparts. One prominent doctor in Chinandega told me that he makes about $450 a month, ten times what a poor Nica earns. That works out to $5400 a year, about one twentieth what the average physician earns in the United States. As important, the visiting doctors have access to vastly greater resources to do their jobs. For that reason, the Nicaraguan doctors are as interested in their guests’ equipment as in their guests themselves. It is customary among the Nicaplast doctors to scavenge their clinics and hospitals for spare or outdated supplies (many medical facilities throw away perfectly good, often unused items left over from procedures rather than repackage them for later use) or solicit equipment from suppliers and bring as much as their luggage limit will allow on the airplane to Managua. This can mean anything from special syringes to television monitors and the high-tech fiberoptic tubes with which gastroenterologists like my wife peer into the gastrointestinal tract and excise small tumors, remove gall stones, and stop bleeding.

Dr. Anthony Zaldonis, a gastroenterologist from Connecticut, showed me the gear that he alone brought on his fourth trip to León: endoscopes, sphincterotomes, biliary balloons, diagnostic guide wires, needle knife, biliary dilation catheter, esophageal balloon, gold probes, biliary cytology kit, radio frequency grounding pads, stents, esophageal band ligators, polypectomy snares, latex gloves, and biopsy forceps—a haul, he estimated, worth $20,000. (On some trips, the medical team brings equipment worth as much as a quarter million dollars.) Most of this donated equipment goes to the host doctors and their hospitals, and the rest of it is used by the visiting medical team when teaching. Often the technology is too expensive or simply unavailable for the Nica doctors, and when that is the case, there is competition to get it. Our host doctors thereby gain a measure of power and prestige that has caused jealousy. During one of my wife’s visits she and another colleague were lobbied aggressively by Managua doctors to visit the capital instead of León and donate to a hospital there. Among the León-Chinandega doctors themselves there are grumbles about who gets what and accusations of hoarding.

But the problem goes even deeper than this internecine competition. Continuity of treatment is often difficult, or not possible, with the donated American equipment because eventually it is used up or becomes inoperable for lack of spare parts. In even the most difficult of gastroenterological procedures, several Nicaraguan doctors have attained a skill level equivalent to that of their North American mentors. Signally, several can perform endoscopic retrograde cholangio pancreatography (ERCP). For this procedure, the doctor pushes a special endoscope down through the patient’s stomach and into the duodenum and then threads a wire up into the common bile duct, which drains bile from the liver; by various means, the doctor can then remove gallstones and treat other obstructions, a faster, cheaper, and usually safer method than the alternative, surgery.

Nicaplast doctors and their hosts are particularly interested in ERCP because painful complications caused by gallstones are common here and long neglected for lack of available treatments. With ERCP's they can potentially treat more patients and avoid surgery. But when the North Americans leave and supplies are used up, however much the Nicas duct tape and jerry-rig, eventually such high-tech procedures stop, and there’s nothing the local doctors can do about it. It means the Nica doctors are dependent on outside help, and in some instances their inability to offer follow-up care puts their patients at risk.

A second, less important, but still significant difference is language. All of the U.S. doctors whom I accompanied spoke some Spanish, although few with fluency. Among Nicaraguan doctors, while there is sometimes faultless fluency, many have almost no English whatsoever. Surprisingly, this situation seldom disrupts the medical procedures themselves, since the technical vocabulary of medicine, based on Latin and Greek roots, is similar in English and Spanish. The language barrier may still become noticeable, however. During a particularly dicey ERCP, while guiding a Nica doctor who controlled the endoscope, in the excitement of giving rapid directions Dr. Mark Reichelderfer (a Wisconsin professor) found himself calling out, "Lefto, si, si, now righto, no RIGHTO!" For the most part, however, the language strain becomes evident in social gatherings. Conversation is halting; discussion of complex issues, other than medical technicalities, bogs down or limps along with generalities. This inarticulateness does not sour the mutual good will, but it does diffuse it. (It might well cause resentment were our hosts to wonder why North American doctors don’t learn Spanish well enough to communicate effectively, although neither my wife nor I saw any expression of it. Yet Nicaraguans share the common international suspicion that Americans feel themselves entitled to walk blithely around in a bubble of their Americanism wherever they go and no matter what they do.)

In fact, the issue of expectations creates a third important difference. During a visit that included hospital work in Chinandega and Puerto Cabezas, Dr. John Hamilton of Wisconsin, a leading member of Nicaplast, told an audience of physicians and medical students in León, "It is the great dream of Nicaplast to help your doctors teach each other and to help the poor people." Later he gathered together his fellow North American doctors and confided, "My goal was to get the doctors here to the point we were twenty years ago. I've done what I wanted. If they have gumption, they’ll continue on their own." Gumption is a virtue much prized in the United States, the idealism of initiative, and the visiting medical team possesses it in plenty. They are each of them people who get things done. In addition to working as subspecialists, keeping up with their own continuing medical education (some also teach in the U.S.), and maintaining families, they gather equipment, make arrangements, recruits others, and fly here, some several times a year and largely pay for it themselves. Here they also work a full day teaching and assisting in procedures, party in the evenings, and on the occasional free day, as now here at the beach, transform themselves into tourists.

For them Nicaragua provides a working vacation, and they often work in spite of obstacles. Once in Puerto Cabezas’ hospital, Dr. Hamilton and two of his colleagues wanted to treat a bleeding stomach ulcer, but the proper equipment for treating the lesion (sclerosing) was not to be had, so they cobbled together a means to convey a medication through a tube and washing it over the ulcer, and the bleeding stopped. Very pleased with themselves, they were laughing as they left the hospital. "I haven’t had that much fun in years," one said. They all have repaired equipment themselves, helped the technicians and nurses, or like Dr. Hamilton’s team found a way around a problem. I have seen their "let’s get it done" attitude flummox their hosts, and even cause some irritation. Moreover, when my wife tells doctors here that she comes from a working-class background (her grandparents were Montana farmers), her remarks are greeted with an air of polite disbelief. The Nica doctors all have doctors (or professions of equivalent status) for parents.

Nicaraguan doctors have energy, skill, and intellect in great abundance, but they work in a society that places restrains on gumption that do not exist in the United States. If, for instance, a part malfunctions in the medical equipment—even something as simple as a light bulb—the doctors are expected not to fix it themselves, or even to know how. Instead, they wait until the right technician is located, he hunts up the replacement part, and he arrives to make the repair, all of which can occur in the middle of a procedure. The lack of preventative maintenance—or the resources to carry it out—and the dependence on limited, hierarchical staffing would take the verve out of anyone’s gumption. But more than that, doctors in Nicaragua occupy a high social stratum, and the expectation is that their behavior, even their practical knowledge, reflects that. On two occasions while doctors were driving us somewhere, their cars had flat tires, and neither time did the doctor know how, or want, to put on the spare himself; as a matter of course they called for a repairmen to drive out and do it. The division of labor is more rigid here than in the U.S., and so whether Nicaraguan doctors will be able to carry on with high-tech medical procedures on their own, as Dr. Hamilton hopes, will depend upon more than their own personal gumption.

The Nicaraguan and North American doctors have grown accustomed to such differences in perspective, by and large. Late in the afternoon of the beach party, many of us stroll south on the sloping gray sand to a lot owned by one of our main hosts, Dr. Juan José Guadamúz. Here a wide thatch palapa shelters a half dozen plastic tables. We all gather round them as Dr. Guadamúz’ wife Georgina (herself an obstetrician-gynecologist) brings out platter after platter of barbecued red snapper that she is preparing in a tiny hut behind the palapa. After lunch the partiers segregate by age rather than nationality. The young people go off to wade in the surf or play volleyball. The rest, a mixture of Nicas and North Americans, remain at their tables and chat, and the atmosphere is peaceful, almost intimate. The Nicaplast doctors here represent a type of U.S. intervention so far divorced from that of the Marines and CAFTA that it appears to go a long way in correcting the view that gringos are rapacious, volatile, and cunning.

Yet like all ambassadors of good will, Nicaplast doctors are essentially fighting a delaying action against their own society. Dr. Hamilton's remark about the goal of Nicaplast—to foster a degree of self-sufficiency that would render outside help unnecessary—would be a wise, progressive guiding principle for the United States to follow. But whether the immense North American appetite for goods, markets, and cheap labor, as well as the pervasive globalization of its consumer culture and its domineering foreign policy, can accommodate a Nicaragua with an improved standard of living and leave its national identity intact—that remains dubious, gumption notwithstanding.
© Roger Smith Feb 2005
Based on material gathered from 2003-2005
irtnogebw at msn.com

More on Nicaragua
Saving Chinandega and other stories in Nicaragua
Dragons and Rum
Dr Buitrago and Ruben Dario

More Destinations in Hacktreks here


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