Cities: El Salvador’s Growing Problem

Urbanization is something that every country faces at one point or another in its development. The US, for example, experienced urbanization during the industrial revolution and on to the early 20th century. Today, many developing countries are also experiencing it. Because it is part of the path to development, urbanization is an indicator worth analyzing in the context of El Salvador as it becomes increasingly problematic, specifically in terms of poverty, violence and health.

 

As nations’ economies move from rural farms to more modern technologies, cities begin to form as hubs for commerce and other economic activity. Urbanization’s momentum grows when even more poor people then decide to relocate to the city in an effort to find better opportunities. This can be seen from Mexico City to Shanghai. Problems arise, however, when cities begin to get overcrowded and the poor create squatting communities along the outside of the cities. Often times these individuals have no rights to the land; more so, living conditions in these communities are terrible.

 

El Salvador has cities that are not unlike those of other developing countries. In fact, about 60.3% of Salvadorans now live in urban areas. El Salvador’s main urban hubs are San Salvador, San Miguel, and Santa Ana. While Salvadorans decide to go to cities to pursue better lives, city life is often not that glamorous. Typically, urban homes are made out of bricks and cement. Homes in the slums however, are essentially huts made out of aluminum, plastic, and cardboard. It is important to note that these homes are especially susceptible to constant flooding in the rainy season. There are also instances where the single water source in these communities is contaminated.

 

Urban poverty in El Salvador currently stands at 56%; that is, more than half of those living in cities are barely able to afford to survive. Fewer job opportunities and high costs of living explain why urban poverty is so widespread. Even so, the urban population in El Salvador is growing by about 1.9% each year while the rural population is only rising at 0.6% each year. It becomes a problem when far too many Salvadorans are living in the cities because the government is not able to provide the necessary services to everyone.

 

Another problem related to urbanization is urban violence. Poverty alone does not explain why crime in cities is more common. It seems that inequality, which is more distinguishable in urban areas, is also a key indicator of crime. Inequality, coupled with daily living conditions, is likely to result in conflict and violence. Violence specifically affects developing countries by stifling necessary economic growth. Urban conflict drains financial capital by requiring greater investments in judicial services and healthcare. Human capital is also reduced by the presence of persistent violence. Deaths and reductions in life expectancy, lower levels of personal security, fewer educational opportunities and lower productivity in the workplace all function to weaken the labor force. Lastly, social capital is also reduced through the ongoing fear and lack of trust within communities that result in less coordination.

 

Health is yet another problem affected by urban growth; slums are inherently unhealthy living arrangements. Because these individuals do not own the land and are residing in informal communities, they cannot demand better living standards from the government. Living in city slums, like those in San Salvador, Santa Ana, and San Miguel, where there has been little to no urban planning also facilitates the spread of illnesses. More than that, traffic accidents and pollution, two seemingly trivial consequences of urbanization, account for an alarmingly high number of deaths and illnesses.

 

While the government has not done much to address the issue of living conditions in the cities and slums, it has attempted to address the issue of crime. As a result of its high crime rates, El Salvador has passed a substantial number of laws aimed at reducing crime. With mixed success, the government has remained dedicated to fighting crime since El Salvador became one of the ten most crime-ridden countries in the world. With that said, the government has done little to address the issues of poverty and health in the growing urban areas.

 

Indeed, urbanization signals progress, however it comes with its own unique set of problems. El Salvador does not have the necessary mechanisms in place to offer everyone in the cities the resources and services they need to pursue a better life. Instead, urban poverty is growing and living conditions continue to deteriorate. Poverty, violence, and health are all variables that interact with one another to create the reality of city life in El Salvador today. As such, one of these factors cannot be remedied without the other two being addressed as well. The government will be forced to address it in the coming years as more and more Salvadorans continue to move to the cities.

 

Women’s Rights Debate Heats Up in El Salvador

El Faro published an article last week discussing the United Nations’ appeal to El Salvador that it amend its laws to accommodate safe access to abortions. The United Nations’ Human Rights Committee issued a report last Thursday asking El Salvador to decriminalize abortion and revamp its dismal record of women’s rights violations. The report emphasizes, “El Salvador is one of the only five countries in the Latin America that maintains an absolute prohibition on abortion, including under circumstances when pregnancy endangers the women’s life.”

El Salvador’s laws restricting abortion have become increasingly restrictive in the last two decades.  Until 1998, abortion was illegal except in cases of rape, incest, fetal anomaly, and when the mother’s life or health was at risk.  Starting in 1998, El Salvador instituted a series of reforms restricting women’s access to reproductive service.  Chapter II of El Salvador’s revised Penal Code now “penalizes women who induce their own abortions or give their consent to someone else to induce an abortion; doctors, pharmacists or other health care workers who practice abortions; persons who encourage a woman to have an abortion or provide the financial means to obtain an abortion; and persons who unintentionally cause an abortion.” The penalty ranges from two to eight years in prison. In 1999 the constitution was amended to define a human being “from the moment of conception.” Although El Salvador is party to many international treaties guaranteeing women’s and children’s rights, and although El Salvador’s constitution grants recognition to these treaties and conventions as equal in status to national law, the country continues to restrict women’s reproductive rights.

The UN report also highlights the concern over violence against women and girls in the country, including rape and sexual violence, which it characterized as “pervasive and widespread.”  The report “demonstrates how El Salvador’s complete ban on abortion health services directly violates of women’s and young girls rights to equality, life, liberty, health and be free from torture. Furthermore, it violates every woman’s right to receive medical attention while preserving patient confidentiality, which is violated by medical personal that have been pressured by the police to report these incidents.”

A blog article in yesterday’s Ms. Magazine touched on the concerns over the links between restricting reproductive rights and increased violence against women when discussing the case of Irma Medrano, a Salvadoran woman who fled the country in 1995 and settled in California.  She has been living with her sister and hoped to escape the dangers of her abusive husband back in El Salvador, whom police investigators refused to investigate citing the violence as a private matter.  Although the Obama Administration has previously recognized fear of domestic violence as a justification for asylum, Ms. Medrano is currently in the process of being deported back to El Salvador despite word that her husband will be looking for her once she arrives.

Access to abortion became a subject of public debate earlier this year after Maria Evelyn Martinez, Director of the Salvadoran Institute for Women (Idesmu, for its name in Spanish), ratified the Consensus of Brazil without the President’s explicit consent. The Consensus was developed during the 11^th Regional Conference for Women in Latin America in the Caribbean, an event sponsored by the Economic Commission for Latin America and the Caribbean (ECLAC) and the United Nations, which took place on the 16^th of July in Rio de Janeiro, Brazil. The Consensus calls for greater protection of women’s rights, and asks that all signing countries reconsider any laws that punish a woman for seeking an abortion and promise safe and secure access to abortion where it is permitted by law. By ratifying the Consensus, Ms. Martinez agreed that El Salvador would revisit its strict anti-abortion laws. Her action is widely unpopular and was harshly criticized before being overturned by President Funes.

Martinez signed the document with the understanding that she was authorized to participate fully in the forum using only her own judgment. In the governing laws of Idesmu it specifically states that the director is authorized to “create, circulate, and promote effective compliance with the agreements ratified by El Salvador in relation to the improvement of women’s quality of life” (Idesmu Charter). Given this language, Ms. Martinez felt that she was able to sign on behalf of the nation without the President’s specific approval.

However, in a public statement in late August, Funes criticized Martinez’ actions and said that he has “never given any consent for the revision of the country’s laws.” He continued, “the national constitution states that life begins at the moment of conception, and as long as this constitution is in effect we must respect its laws” (El Faro). He also stated that he would communicate with the coordinating bodies of the Consensus of Brazil to inform them that Ms. Martinez was not authorized to sign the document and that El Salvador would be withdrawing its signature from this aspect of the agreement.

Ms. Martinez has defended her actions by pointing out that this is the fifth time she has signed an international document calling for the revision of El Salvador’s abortion laws, but no President (including Funes) has ever criticized these decisions in the past.

Official responses to the event were mixed. Many FMLN representatives have asked for improved communication and coherency between government offices so that misunderstandings like this one can be avoided in the future. The Vice-minister of Health, Violeta Menjivar, and the second in command for the FMLN Legislative group, Norma Guevara, openly expressed their disappointment at the President’s refusal to reconsider the law. El Faro took this opportunity to conduct an in-depth interview with Ms. Martinez, questioning her about her role as Director of Idesmu and her personal beliefs.  Archibisop of San Salvador, José Luis Escobar Alas, publicly announced his support for President Funes’ decision to uphold the constitution.

In contrast, public response to the event has been overwhelmingly consistent, with almost all Salvadorans opposing any changes to this aspect of the constitution. El Diario de Hoy polled public opinion on the issue and found surprisingly homogenous results: 93% of respondents said they were against modifying the constitution to allow abortion; 76% support Funes’ decision to modify El Salvador’s commitment to the Consensus of Brazil, and 32.7% believe that Ms. Martinez is “mentally ill” for signing the document.

With such an overwhelming public response and the clear agreement of the President it seems unlikely that El Salvador will seriously reconsider its abortion laws anytime soon. El Salvador remains one of only 3 countries in the world that have increased restrictions to abortion care in the last 50 years; regulation in every other country has stayed the same or become more lenient over time.

Epidemic of Bacterial Conjunctivitis Declared in 12 Departments

In addition to the increase in cases of dengue and repertory illnesses the Ministry of Health has stated that El Salvador is also experiencing an epidemic of Bacterial Conjunctivitis, commonly known as pink-eye. Conjunctivitis is a microbial infection involving the mucous membrane of the surface of the eye.  It is usually a benign, self-limited illness, but can be serious or signify a severe underlying systematic disease. Occasionally, significant ocular and systematic morbidity may result.

The Ministry of Public Health and Social Welfare (MSPAS) reports that the increase in cases of Bacterial Conjunctivitis led them to them to declare an “alarm” in 12 of the 14 departments of El Salvador. The only departments not included in the declaration were San Salvador and San Miguel.

As of August 2, 2010, 38,358 cases of Bacterial Conjunctivitis have been reported, compared to only 2,400 cases in 2009. Additionally, authorities have noted that the greatest increase in cases observed has occurred in the last few days. The Director of Health Surveillance, Julio Armero explained, “just on Sunday (August 1st) 76 cases were reported and on Monday we had 56.” In response the ministry has begun to work on a campaign to prevent further spread of this illness.

Violet Menjivar, the Vice Minister of Health clarified that the alarm was only declared in the 12 departments where an epidemic of Bacterial Conjunctivitis is present. People living in these departments should therefore undertake proper precautions to avoid catching the illness these include, washing ones hands and not touching ones eyes or mouth. These precautions are similar to the ones recommended to prevent respiratory illnesses.

Hospital Strikes

For the past week, union strikes and protests have caused partial closures and diminished services to patients at four Salvadoran hospitals.  Members of the Professional Union of Nursing Workers of El Salvador (SIGESSAL) from the José Molina Martínez National Psychiatric Hospital in Soyapango have partially stopped work since last week while they demand the removal of the chief of nursing and several security guards, accusing the latter of patient abuse and denying entrance to the hospital to those in need.  The workers also say that the Director General of hospitals has refused to sign agreements made last June with the union.

Administrative workers from the Rosales National Hospital are also on strike to show solidarity with their colleagues from the psychiatric hospital.  They are also protesting the lack of order and misuse of staff within the hospital administration, as well as the depletion of 25% of the hospital’s basic medicine supplies (for more information on the lack of medicine, see La Prensa Gráfica).  “We want the new [2011] budget proposal to [better] organize the [staff] positions [according to job titles, descriptions and qualifications],” said Mario Arévalo, Secretary General of SIGESSAL (for more information, see El Diario de Hoy).  The union is also asking for a bonus of $300, which has already been given to workers in the Education and other ministries.  Government officials have criticized the measures taken by the unions, saying that they are counterproductive.  Mauricio Ventura, President of Rosales Hospital, said that while the union workers are disparaging the lack of medicine, they prevent more from being ordered by shutting down the administrative side of the hospital.

Since the weekend, members of SIGESSAL have protested hospitals in the cities of Ilopango and Zacatecoluca, demanding signatures on their contracts with the Ministry of Health and complaining about the lack of medicine and other necessary supplies. The protesters have stationed themselves outside the hospitals, hanging banners and blocking entrance into the facilities.

With increasing violence throughout the country and devastating poverty, it is crucial that patients have access to appropriate and efficient care.  Lack of medical supplies and poor organization are serious obstacles in the way to providing this care.  Even the directors of Rosales National Hospital have recognized that the lack of medicine has reached a crisis point and the Hospital is threatened with collapse.  Further exacerbating the problem are the high costs of medicines.  El Salvador has some of the highest costs for medicine in the world, second only to Guatemala in Central America while distribution companies mark incredibly high profit margins.  Eduardo Espinoza Fiallos, Viceminister of Sectorial Politics in the Ministry of Public Health has criticized the formation of monopolies among distribution companies, leading to such high prices.  “[The ministry] has discovered anticompetitive practices,” said Mr. Fiallos, noting that there has been extensive integration and buy outs between laboratories, distributors and pharmacies (for more information on high drug prices, see Diario CoLatino).

Rain Rain Everywhere…. And Not a Clean Drop to Drink?

Around the world, over 1 billion people lack access to clean water, and over 3 million die each year from complications caused by drinking untreated water.  The United Nations Development Program attributes the global water crisis to “power, poverty and inequality, not in physical availability.”

El Salvador, unfortunately, is a case in point. Located in one of the most water-rich regions of the world, some areas of El Salvador get up to 6 ½ feet of rainfall each year.  Over 90% of all surface water in El Salvador, however, is contaminated, and more than half of the Salvadoran population consumes untreated water.  1.4 million Salvadorans live without a dependable water supply.  (1.4 miliones no tendrán acceso al agua en el Día Internacional, DiarioCoLatino, March 22) In a recent study of the 124 monitored sites in El Salvador’s 55 rivers, none were assigned a quality rating of good.  60% were classified as regular, 31% poor, and 9% terrible.  This is a substantially lower overall quality rating than observed as recently as 2007. (Ríos salvadoreños no presentan buena calidad en agua, La Prensa Gráfica, March 22).

Beyond statistics, the issue is a daily feature of life in El Salvador. Tim’s El Salvador Blog recently posted an article describing how water scarcity affects the lives of Salvadoran rural populations. It is undeniable that water security is a necessary achievement before any sustainable development can take place.

Much of the water problem may be attributed to the plethora agencies that are responsible for managing El Salvador’s water resources. These agencies are responsible for gathering and protecting water resources, supplying families with potable water, and treating wastewater.  Few, however, actually achieve their objectives.

Additionally, the Ministry of the Environment, police, and other law enforcement agencies fail to enforce the country’s environmental laws in a manner that prevents contamination of rivers, lakes and water tables.  Water distribution is too often determined by wealth and political connections, and no one agency controls distribution nationwide. To date, El Salvador still does not have a wastewater treatment plant, and sewage is often dumped straight into local stream and rivers where people collect drinking water, bathe and wash clothes.  Lacking any one entity to coordinate their activities, these agencies often clash over water policies and allocation of resources.

The Administración Nacional de Acueductos y Alcantarillados (ANDA) is the agency that provides the most water services in El Salvador, covering 181 of the 262 municipalities in El Salvador, around 30% of the total population. ANDA’s primary focus is on San Salvador, Santa Ana, and San Miguel, where it generates almost 70% of its revenue. While water services are regular throughout these major cities, rural municipalities may only have access to water 4 to 16 hours a day – some may be without for three weeks or more. This means that poor campesinos can spend 4.9%-13.6% of their productive time collecting water for household use.

The rural municipalities and communities that ANDA does not serve must depend on individual private companies, municipal water operations, aid organizations, or local private voluntary organizations.

Over 100 housing developers have built their own autonomous urban water systems because at the time of construction ANDA would not or could not connect them to their services. These systems are then handed over to private companies for management and regulation, which generally connotes high tariffs and inaccessibility for poor populations.

83 municipalities provide services directly to their residents, almost exclusively through underground systems. This water is available to anyone in the municipality, but the organization managing the program is generally unable to offer any substantial subsidy (as ANDA provides), and therefore it remains out of reach for many of the rural poor.

There are currently 12 signed agreements between ANDA and decentralized service providers, permitting them to use ANDA’s infrastructure to provide services to underserved communities. These agencies manage the provision of services completely autonomously, with little (if any) supervision from ANDA.

Finally, there are over 800 community based organizations, most of which are rural cooperatives. Some examples are the Junta de Agua, and the Asociación de Desarrollo Comunitario. This type of organization serves 30% of the population, almost all of which is in rural areas that have limited, if any, access to ANDA.

The lack of regulation of these various water service providers adds to the disparity in water services from community to community. Too many communities still do not have a water system that pipes water to homes, forcing families to spend hours every day carrying water from streams, rivers or local wells to their homes.  The lack of centralized legislation or monitoring means that each of these organizations is able to provide services how they choose, and for how much they choose. Prices of water can vary significantly depending on where you live, and consistent access to water is not guaranteed even if one of these organizations functions in your area.

Though well intentioned, aid organizations often fail to understand the exact needs or power structures of the communities they intend to help. As a result, their efforts do not solve the long-term need for water services. Communities that lack developed water systems have to rely on shallow wells or contaminated surface waters, which often result in serious public health issues.  Communities along Rio Acelhuate, for example, consume river water that is contaminated by heavy metals and industrial waste resulting in serious health issues among the population.

The extreme surface water contamination has several sources. Deforestation, which has eliminated over 85% of El Salvador’s forests, has resulted in widespread erosion of topsoil. When the soil runs off, it carries with it residual agrochemicals and naturally occurring heavy metals. As farmers plant crops on eroded and depleted land, they use an increasing amount of fertilizers and pesticides, which seep into shallow water tables and nearby streams and rivers. El Salvador has fairly progressive environmental laws on the books, but enforcement is weak. As a result, individuals and corporations dump untreated waste and dangerous chemicals directly into water sources. The minister of the Environment, Herman Roza Chávez states that the Environmental Law already in place includes sufficient provisions to construct a sustainable policy of water use and does not support the development of an additional water law. (Gobierno en desacuerdo con la Ley General de Agua, elsalvador.com, March 22, 2010)

The Salvadoran government has discussed enacting legislation to better coordinate the management of water resources, but has thus far been unsuccessful.  A general water law and a potable water law were proposed to the Legislative Assembly in 2006 and 2007 respectively but neither was successful.  The Salvadoran Centre for Appropriate Technology (CESTA), the Salvadoran Association of Engineers and Architects, and several environmental organizations from around the world call for a water law to expand water access and improve water quality throughout the country. (El CESTA solicita al Gobierno crear la Ley del Agua, DiarioCoLatino, March 23)

One provision in many water laws is privatization of water management. Previous administrations have thought this to be a good way for the government to generate income while ensuring better water services for more communities. Privatized water management, however, has resulted in higher prices and lower water quality in many of the countries that have tried it. The Peruvian government, for example, privatized its water resources in the 1990s, only to take them back over after citizens complained that they were paying more for less. ANDA however, calls for the creation of a water law that gives the company even more control over contamination, treatment plants, and wells.  (Gobierno en desacuerdo con la Ley General de Agua, elsalvador.com, March 22, 2010) Salvadoran civil society has been nearly united in its opposition to privatization of water resources. In October 2007, 125 organizations mobilized over 25,000 people in a march against privatization. They also called for the government to recognize water as a basic human right, and for greater investment into water services.

Despite this public outcry, the extreme nature of the problem, and recent international attention, water availability and scarcity in El Salvador remains a pressing national problem. Much more research, legislation, and infrastructure is necessary to remedy this situation and create reliable and inexpensive access to clean water for all Salvadorans.

NE VOSH Medical Delegation

In January, Voices on the Border hosted the NE VOSH medical delegation in the Lower Lempa region of El Salvador, providing a variety of services. We were pleased to come across a story this morning in the Jamestown Press about the delegation.

By Iain Wilson

Each year, Doctor Joe England of Jamestown Family Practice takes one week off in January. But it’s not so he can sleep late and sip cocktails at a destination resort. England spends his week volunteering in a country that can use his help. This year, he spent a week in El Salvador, a Central American nation that neighbors Honduras and Guatemala. There, he – along with a group of approximately 50 volunteers – conducted a four-day clinic in El Salvador’s lower Baha Lempa region.

The clinic provides basic medical services, but also hands out eyeglasses, performs cataract surgery and offers Pap smears to villagers in this fertile river basin. “It’s a very, very busy four days,” England said of the week’s hectic pace. This year, he and other volunteers treated 2,600 patients, splitting care about evenly between medical attention and vision needs. Cataracts, generally less common in the U.S., are quite common in El Salvador. By removing them through eye surgery, volunteers literally gave sight to the blind. This year’s trip was the first in El Salvador to offer these valuable eye procedures.

Jamestown’s ties to these volunteering trips run deep.

“The guy who really started all of this is an optometrist who goes by the name of Carl Sakovits,” England said of the Jamestown resident who originally lobbied him to join the group.

Sakovits, who practices in Bristol, joined the group while at optometry school at the State University of New York. More than a dozen of the 50 volunteers either live in Jamestown or have direct island ties – Sakovits recruited England, and the two have been scouting ever since.

“We managed to get a lot of local people to start getting involved with this,” England said.

Two organizations made this trip possible, he said. England is part of a group called Northeast Volunteer Optometric Services to Humanity, which organizes the trip. The Northeast branch is part of the national VOSH network, an organization that has sent physicians and optometrists to Central America every year since 1988. According to the group’s website, its aim is to provide “vision care to people around the world who cannot afford or obtain it.” Last year marked the group’s first trip to El Salvador, after years of work in Nicaragua, a Central American nation that sits south of El Salvador.

The second group, Voices on the Border, is an American-based non-profit that works to promote just and equitable development in El Salvador. This group handles some diplomatic issues and paperwork, while helping to identify the more pressing medical problems that locals face. Volunteers in El Salvador are stationed in Nueva Esperana, a name that translates to “new hope.” Most citizens in the region are refugees; many were displaced when war erupted during the 1980s. As there are no four-lane highways, the commute – made via cattle truck – lasted only 10 minutes and left around 7:15 every morning. But the sheer volume of patients proved to be a difficulty, England said. “After four days, we’re running out of stuff,” he said.

Materials for the trip, including all eyeglasses and medications, were provided entirely by the volunteers. England estimated the cost to be $15,000. Though no credentials are required to work as a clinic volunteer, many of the names on the attendee list include medical titles. All of the work is done free of charge, and volunteers pick up their own travel costs as well. Far from posh, accommodations for the group include cinderblock guesthouses at a nearby convent.

Recent Salvadoran medical school graduates are required to serve communities outside of the nation’s capital, San Salvador, for one year. At the time of England’s arrival, the communities were waiting for these new medical school graduates to arrive, he said. “When we’re there, we’re kind of putting our fingers in the dike,” he said. In a poor third-world country like El Salvador, distribution and availability are the two largest constraints on effective healthcare, England said. There are clinics and there are doctors, he added, but generally, “They really don’t have much to work with.”

Looking forward, England mentioned his intention to develop a system for diabetes management, something he said the area sorely lacks. He also said that most people who require major medical attention get it, but “it’s the day to day stuff that kind of gets lost.” A planning meeting for the 2011 trip will likely happen as soon as next week, England said, adding that there is much to be done for the upcoming trip. “We’re trying to develop a longer term relationship that can have longer-term effects,” he said. It’s a prospect about which he’s optimistic.

NE VOSH doctor talks to a patient through a translator

“Our contacts down there are very good, and our mechanisms for working through government red tape are working well, which is a big issue,” he said.

During his years as a volunteer, England’s role has shifted from participant to something more closely resembling a manager, he said. He chuckles as he explains his new perspective on the trip.

“Your idea of a successful trip is nobody got injured, we got through the government glitches, we didn’t have any major loss of equipment,” he said. “Your view begins to change.”

And the group, after days of tireless work and thousands of patients, used the last day to take a more traditional approach to winter travels to warm locations.

They took a day to go to the beach, England said.

Continuing Virtual Delegation Calls on Women’s Rights Issues

In continuation of our Virtual Delegation series on Women’s Rights in El Salvador, we hosted Dr. Miriam Cremer from Basic Health El Salvador to discuss her more than 12 years experience addressing women’s health issues in El Salvador. Over the years, Dr. Cremer has initiated many programs around the country to provide cervical cancer screening, reproductive health education, and training of local health professionals. In addition, she has partnered with local doctors and organizations to conduct surveys on sexual behavior, knowledge and attitudes about reproductive health services and contraception, and other related topics.

Dr. Cremer and Basic Health El Salvador lead several delegations a year, many of which focus on screening women for cervical cancer and training local health workers to conduct screenings. Because cervical cancer is the leading causes of cancer mortality among women in El Salvador, Dr. Cremer’s team stresses the importance of screening and treating women in one visit, so to avoid barriers such as transportation or day care for children from interfering with follow-up visits.

When asked about conducting surveys in El Salvador, Dr. Cremer responded that the women in the communities where they have conducted surveys are more than willing to participate, though the more sensitive the question the more conservative the answer.  For example, when women are asked how many sexual partners they have had, the most common answer is one, and when women answer two they are quick to add that their first husband was killed in the war, or something of the nature. This suggests that the participants either have very few partners, or that some are not completely honest about their sexual behaviors, despite their willingness to participate. Younger women are the exception, and are beginning to report more sexual partners, either suggesting that they indeed have more partners than women of previous generations, or that they are more comfortable discussing such issues with their health care providers.

Dr. Cremer also discussed her experience with promoting methods of family planning. In El Salvador the most common form of birth control is Depro Prevara injections, though many women choose tubal ligation, even among young women under 30. In focus groups in the United States, most of the women who have a tubal ligation before the age of 30 express regret about their choice. The same is true in El Salvador, though its reliability and accessibility make it a popular option.  Dr. Cremer suggested that the relative high rate of tubal ligations is also due to a lack of alternatives being offered by health care providers.

Dr. Cremer also explained that other forms of birth control, particularly oral contraceptives and injections, are used with frequency but are often less than ideal for most women because they must make frequent visits to their doctor for injections or pills, which is often difficult for women who work or have children. Given the MInistry of Health’s small budget, sometimes these forms of contraception are unavailable, meaning that women who use them are often unprotected. Considering all of these factors, Dr. Cremer has found that intra-uterine devices (IUD) are one of the most effective forms of long-term contraception. IUD insertion requires only a single visit to a health provider and is effective for a long period of time, in most cases 5-12 years. The main obstacles to greater IUD use are cultural myths and misconceptions, which could be dispelled with greater education and outreach.

Please join us next week – our panelists will include two rural health workers who will talk about their experiences providing health care to women and families in the Lower Lempa region of El Salvador. For the call in numbers and more information, please drop us a note at voices@votb.org.

Interview with Ana Carcedo

December 1 2009

Ana Carcedo is the Director of CEFEMINA (Feminist Information and Action Center) in San José, Costa Rica.  Partnering with UNIFEM and Horizons of Friendship, CEFEMINA has been conducting much needed research into the past decade’s sharp increase in femicides in Central America.

Ms. Carceredo was careful to distinguish between homicides involving women and femicides where women are targeted based on their gender.  In 2000 the average central American female homicide rate was 3 out of every 100,000 women.  It has now doubled to 6 out of 100,000 and has reached 10/100,00 in the more violent of the countries: El Salvador, Honduras, Guatemala, and Dominican Republic.  Their research shows than three quarters of these murders are in fact femicides.

The researchers are finding that these femicides fall into five scenarios. Domestic violence is the most traditionally recognized motivation for femicide, but violence stemming from both organized crime and gangs has become alarming.  Organized crime circuits are responsible for human trafficking, most often victimizing women.  The rising influence of gangs such as MS 13 and the 18 heavily exert control over women in marginalized urban communities.  This scenario has become the most prevalent cause of femicide in several countries.  Femicides are also linked to acts of vengeance. For example, loan sharks will target a debtor’s wife.   Finally, researchers have defined a scenario of misogynist cleansing.  These crimes demonstrate an extreme level of violence against its victims, including mutilated genitalia, degrading words defacing the corpse, and evidence of sexual and/or other forms of torture.

The territory for violence has been re-drawn to increasingly include women.  Where disputes were more often resolved between those directly involved, it has become more common to see violence against wives and daughters.  Also, such acts are more often seen in the street – they are no longer hidden behind private doors.  There are fewer and fewer secure areas for women to find refuge.

Trends show that victims are overwhelmingly young, and the crimes are much more likely to be committed with firearms.  The average age of femicide victims is between 15 and 25.  Younger women are more vulnerable in relationships where they are un-able to set limits, leave their partner, or seek support.  It is also largely younger women affected by gang violence.  They can be either targeted by rival gang members or subjected to violence from with in their own gang’s hierarchy.  Whereas 20 years ago femicides were more often linked to domestic violence and committed with other weapons (armas blancas) such as knives, machetes or other farm implements, today’s crimes are predominantly committed with guns.

CEFEMINA’s research also looks at the judicial and public media response to the incidence of femicides.  The findings come of no surprise, but few investigations provide the necessary documentation of these responses; which are needed for further analysis.  Within Central American judicial systems there is a consistent pattern of negligence.  Police do not investigate, they do not collect evidence, and they do not identify guilty parties.  They often arrive at crime scenes and assume a scenario based on circumstantial evidence.  For example, if a young woman’s body is found along the street of a drug dealing territory, they close the case on the assumption of a drug related dispute.  Evidence of sexual violence is not taken into account and no other hypothesis can take form.  Without proper investigations it is difficult to determine whether a women is a victim of a homicide or a femicide.  Researchers have had to depend on media reports of the crimes to make the distinction. The study has followed several cases all the way through the judicial system to identify exactly what obstacles exist and to offer viable reforms to remove them.  If Central American countries do not take action against the violence and strengthen their judicial systems to decrease impunity, these trends will only grow worse.



408 New Cases of Dengue in El Salvador

The Ministry of Health reports that last week 408 people were admitted to hospitals and diagnosed with Dengue. Two of these patients were in serious condition and admitted to the ICU. Yesterday, the Vice Minister of Health announced that the Ministry is currently concentrating more resources on preventing new cases and limiting the complications in current cases.

Though the number of cases in the western region of El Salvador is higher, the overall numbers in the rest of the country have begun to decrease in what has been a difficult year so far.

Past prevention efforts have achieved relatively high levels of success, leading public health officials in El Salvador to conclude that it is possible to defeat dengue outside of the hospital. Preventative steps include eliminating all standing water, thereby depriving mosquitoes a place to breed, and treating water storage containers so that mosquito larvae are unable to survive. Public health officials consider an increase in the incidences of dengue as an indication that they are failing to implement their community interventions appropriately.

Chronic Renal Disease in Lower Lempa of Usulutan, El Salvador

In recent years, chronic renal disease (CRD) has become a serious public health concern throughout agricultural communities in Latin America.  The Lower Lempa region of Usulután, often referred to as El Salvador’s breadbasket, is no exception. Over the past ten years or more, farmers are diagnosed with CRD, a disease in which the kidneys fail to function adequately, at an rate of 30-45% of men above age 30. The number of cases has risen in recent years, and doctors and researchers are puzzled, as their patients are not traditional candidates for CRD.  Though similar epidemics of CRD are appearing worldwide, few in the public health field have undertaken in-depth or conclusive studies to determine its causes.  The World Health Organization (WHO) and Sri Lankan government recently began to investigate CRD in Sri Lanka, but they have yet to publish any findings.

Causes

These abnormal cases of CRD are most prevalent among male farmers, often young, who do not have the pre-existing illnesses, such as hypertension or diabetes, that are traditionally associated with the onset of CRD. In a 2001 study done in Jiquilisco, Usulutan, 71% of 132 men with CRD showed no signs of hypertension, diabetes, or other known risk factors, and suffered from the disease seemingly without cause. Studies conducted in Sri Lanka indicate that renal disease could be linked to any one of a number of factors, such as use of low quality aluminum utensils, cadmium ingested through food, fluoride in the ground water, and consumption of poor quality alcohol, but no decisive conclusion has been reached.

Many in the medical community believe that the most likely of these is the presence of cadmium in the environment. These farmers may be ingesting cadmium from any number of sources. It is used as an artificial phosphate in fertilizers and is also a byproduct of mining. If present in the soil or water, cadmium may be ingested by livestock and fish, or absorbed by crops, and then ingested by humans. Cadmium is also linked with other chronic and acute illnesses that include:

• Diarrhea, stomach pains and vomiting
• Reproductive failure
• Damage to the central nervous system
• Damage to the immune system
• Psychological disorders
• Cancer development

CRD in the Lower Lempa

As mentioned, the 2001 Jiquilisco study found that 30-45% of men over age 30 in the municipality of Jiquilisco suffer from CRD. In 2005 the Fondo Social de Emergencia de Salud (Emergency Social Fund) reported that 23 people, in a population of about 40,000, died from renal failure, while the Salvadoran Ministry of Health reported only one death. Similarly situated communities in countries such as Sri Lanka and Nicaragua report as many as 200-300 deaths a year, indicating that the occurrences in Jiquilisco are likely to be under-reported.

Despite such high rates of CRD in the region, the local hospital and clinics rarely have the appropriate medications or dialysis machines necessary to treat patients.  The government-run clinic in La Canoa (a small community in the Lower Lempa of Jiquilisco), for example, rarely has the high-blood pressure medications used to treat CRD.  Even if the resources for detection and treatment were readily available, most patients are unable to afford them.  Though El Salvador’s Ministry of Health and other government agencies have neglected the problem, communities have begun to help themselves.  For the past few years, the Fondo Social de Emergencia de Salud has been educating people about the causes and prevention of renal disease. Their small size and few resources, however, limits their impact.

Patients diagnosed with CRD often require hemodialysis, but the government clinics and hospitals have so few machines that they are generally put on waiting lists. An alternative to hemodialysis, which must be done at a hospital or clinic, is peritoneal dialysis, a procedure in which the abdominal cavity is filled with dialysis fluid that removes toxins from the blood. Peritoneal dialysis can generally be done at home, but there is a shortage of supplies for patients, and most cannot afford the permanent abdominal catheter. In order to have the treatment, patients must go to a clinic twice a week to have their abdomen punctured for a temporary catheter.  The logistics of getting to the clinics, and having an abdominal catheter are significant for farmers in the Lower Lempa, and many stop treatment after a couple visits.

The public health and medical communities have yet to decide on recommendations for combating CRD among young, seemingly healthy farmers.  In Sri Lanka, the government is being proactive and testing all farmers for CRD.  In addition to more testing, government and non-profit health providers ought to take steps to prevent further cases, but because the cause of these CRD cases remains uncertain, its difficult to inform farmers how they may avoid contracting the disease. Ideally, communities ought to be testing and changing their sources of food and water, and using organic fertilizers. Already impoverished and marginalized, such steps are daunting for communities such as those in the Lower Lempa. Until the medical community is able to provide more complete prevention programs, the Ministry of Health ought to invest in the medications and machines necessary to provide adequate treatment.  In 2007 and 2008, Hospital Rosales in San Salvador opened two new wings to treat CRD patients, but they are hardly sufficient.