Short-Staffing and Overwork
Many participants voiced a frustration with being unable to provide care “con calidez”, or warmth and compassion, indeed being barely able to perform the minimal necessary tasks for their patients. By their accounts, one or two auxiliares together with one nurse are typically responsible for 40, 50, or more patients in the public hospitals. There was widespread agreement that fatigue, injury, and illness as a result of the workload intensity were on the rise, and that these produce a vicious circuit with absenteeism in what is a relatively aged nursing workforce. Study participants traced the abysmal staffing ratios to the 1990s when massive cuts to health-care spending produced a 64% drop in the number of professional nurses in the Ministry of Health facilities. But they were also irritated that the FSLN had not restored the positions that were closed in that period. At the same time, patient demand has been on the rise since the FSLN abolished the user fees imposed by their predecessors.
A Culture of Complaint and Abuse
Compounding the strains of the staffing deficit is that patients in the public health-care sector seem to have acquired a heightened consciousness of rights to health that were disregarded under the previous regime. At the root of this is the government’s populist messaging that encourages people to vigorously assert their entitlements. This has generated a source of stress that has clearly worsened since 2006, namely verbal abuse by patients and their families, along with threats of denunciation and legal action. A 2012 survey-based study by the Nicaraguan Nurses’ Association (AEN) recognizes this as a mounting problem and characterizes it as gender-based violence toward nurses. Several participants noted that the rising use of social media exacerbates this culture of complaint. The more affluent patients in the for-profit facilities also verbally aggress nurses and other health-care staff, according to my participants’ accounts. In that sector, nurses are subject to a “customer is always right” ethos, and are unable to unionize.
The Political Environment for Collective Agency
We might think of nurses’ unions and professional associations as vehicles for confronting these problems. But in Nicaragua, I found that these and other spaces for advocacy and education were greatly constrained by a government increasingly intolerant of dissent. Nurses in Nicaragua lack a union specific to their occupation. More problematically, the main organizational vehicle in the public health-care system, the Health Workers’ Central (FETSALUD), is tightly linked to the governing party. FETSALUD’s president is among Daniel Ortega’s circle of close advisors with the power to override Ministerial decision-making. Not surprisingly, the Federation fails to act as a countervailing power, blocks labor militancy in numerous ways, and rewards compliance with the authorities in the workplace. By 2013, the government was also intruding on the Nurse Association’s long tradition of non-partisanship in various ways, for example, by ensuring that Ortega loyalists took key leadership positions. Even the renowned and independent Centro de Investigaciones y Estudios de Salud (CIES), which offers post-graduate degrees and courses in health policy to local and international students, was being pressed by state authorities to rid its curriculum of anything it deemed as questioning its policies in this sector.
The Current Crisis: Authoritarian Violence and Health-Care
Sparked by the government’s announcement of a new retrograde pension policy, the student-led protests that started in April 2018 carried a much larger load of grievance and outrage from watching the deepening of low-intensity dictatorship over the past twelve years. In addition to the various manipulations by which Daniel Ortega and his now Vice-President wife have deepened their personal grip on power, one of the most baffling of their non-consultative decisions in recent years was to build a new canal that would have bisected the country, an ecological nightmare that appears to be halted for the time being.
The worsening state repression that has so far taken the lives of over 300 people has begun to target public sector health-care workers for the crime of treating wounded protestors. Several dozen health-care employees including doctors and nurses who disobeyed orders not to treat such people have been fired, and in some cases their relatives interrogated and threatened in order to locate those in hiding (Moreno 2018; Salazar 2018). Here we see an echo of the weeks and months following the 2009 military coup in Honduras, where, amidst the massive uprising triggered by the ousting of the democratically elected President Manuel Zelaya, nurses and other health-care workers were similarly confronted in emergency rooms and clinics with bodies of those maimed by government forces. There, too, nurses and doctors who treated and protected these patients subsequently faced reprisals for their caring stance (Pine 2013). Nicaraguan health-care workers and their families are now among the many who have fled persecution to neighboring Costa Rica, along with journalists, human rights workers, and other activists (Phillips 2018). Given that specialists are among those being fired, there may be consequences for the quality and availability of care in the more protest-intensive western region of the country (Salazar 2108).
No one can predict how this tragic set of events will play out, and obtaining information about how nurses are responding to the violence is challenging. If the fiercely critical attitudes that nurses in my study displayed toward government, and their expressions of approval for workplace militancy including strikes, are any indication of what is to come, perhaps we will see an emergent new assertiveness in the profession, similar to that documented by Pine (2013) in Honduras. In any case, there is a need for international solidarity with these courageous care-givers, to put the Ortega government on notice that the abuse of health-care workers will not be tolerated.
Article in LARR:
Kowalchuk, L. (2018). Patriarchy, New Left Post-Neoliberalism, and the Valuing of Care Work: The Labor Conditions of Nicaraguan Nurses under Sandinismo’s “Second Stage”. Latin American Research Review, 53(4), 741–756. DOI:http://doi.org/10.25222/larr.401
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Picture in the article: https://www.nursesworkincentralamerica.com/from-the-field.html