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Dr. Ciro Ugarte of the PAHO: “Nicaragua’s Increased Mortality is from COVID-19

Dr. Ciro Ugarte of the PAHO: "We have the expertise and the capability to perform an audit. We hope Nicaragua will accept this mission for evaluation"

The Nicaraguan government alleges only 154 deaths have occurred in the country from COVID-19. This situates Nicaragua as the Central American country with the second lowest COVD-19 mortality, after Belize. However, Confidencial has documented an alarming increase in mortality from heart attacks, pneumonia, diabetes and high blood pressure. These conditions have accounted for over 6,000 deaths during the first eight months of the year.

“The increased mortality is directly or indirectly associated with COVID-19,” confirms Dr. Ciro Ugarte. He directs the Department of Health Emergencies of the Pan-American Health Organization (PAHO). Dr. Ugarte recently consented to this interview with Confidencial.

The last report of the Nicaraguan government registered a total of 5,353 confirmed cases of COVID-19 and 154 deaths.  This would be the second lowest index in the region, after Belize.  It would mean that only 1.5% of the COVID deaths in Central America occurred in Nicaragua. Can the PAHO verify this? Is this the official information for Nicaragua?

Well, it’s Nicaragua’s official information. We’ve expressed repeatedly that it’s impossible to adequately evaluate the situation, given the very scant information received.  I believe that information was offered with an eye to reporting only the information that was strictly necessary. They didn’t expand it by offering other essential data. That’s why our reports note that it’s government information, and that other sources have different information than the official data.

On October 11th, Confidencial published an analysis based on the officially reported deaths from pneumonia, heart attacks, diabetes and hypertension. This analysis reveals that from January to August 2020, there was an excess mortality of over 6,000 people. That is, over 6,000 more people died this year than in 2017 and 2019. Nicaraguan doctors and health workers attribute these deaths to the COVID-19 pandemic.  How does the PAHO see this new information on COVID-19?

The information on mortality must be evaluated and analyzed through a more exhaustive study. This would include a review of the death certificates, plus reports from health services and other entities that register deaths.

The way death certificates are filled out is a global problem. Nonetheless, in the current conditions, the increased mortality in countries such as Nicaragua, is associated directly or indirectly with COVID-19.

Specifically, let’s look at illnesses such as hypertension or diabetes or heart attacks.  If we see them as original causes of death, we can infer that sufficient health services are lacking. The health system isn’t able to offer adequate attention to those people. Because when a health system is solid, that group of people usually don’t die.  Thus, the range of deaths from these causes should be similar or slightly higher than in previous years. If the increment is substantially higher, there’s clearly some other factor at play. In this case, it’s COVID-19.

PAHO’s recommendations

The Nicaraguan Ministry of Health describes these deaths as comorbidities and they separate them completely from COVID-19. For the PAHO, is this an accepted practice for health ministries in other Latin American countries?

No. The work we’re doing with several countries, like Mexico, is conducting an exhaustive analysis of the excess mortality.  We’ve seen this during the COVID-19 pandemic.  In Mexico they’re being straightforward with their death statistics, and clearly the increment in deaths is principally associated with COVID-19.

It’s true that the health services are saturated with Covid patients, or have restrictive mechanisms regarding access for other illnesses. It’s also true that in some cases the population decides not to go to the health centers. Due to these things, an increase in deaths from other causes is probable. However, this can’t explain a drastic increase in fatalities.

So, the answer is that we’re working with a number of countries: Mexico, Ecuador, Brazil and others. With their cooperation, we’re analyzing the mortality from Covid and other causes.

If these projections are corroborated, Nicaragua would be clearly the Central American country with the greatest number of COVID-19 deaths.

If we associate that entire quantity of excess deaths in Nicaragua with COVID-19, we’d have to do so elsewhere. That is, to do a comparison of the deaths, we’d have to do the same in other countries.  Other countries are also reporting the deaths from COVID-19 and deaths from other causes.

Hence, we’d have to perform a similar analysis to have a comparison of the situation in all the countries.  But, effectively as you say, Nicaragua would surely not be among the last places [for COVID mortality].

To what can you attribute this high level of lethality of the pandemic in Nicaragua? Nicaraguan doctors and health workers have questioned the lack of prevention on the part of the authorities. This was especially true in March and April. During those months, the government promoted massive crowd events and didn’t orient preventive measures for the population. PAHO itself was even criticized for their complacent attitude regarding that lack of prevention on the part of the authorities. Can it be determined if there was negligence regarding the pandemic?

We’ve issued specific recommendations, both privately, and with all the countries during those technical conversations.  In the case of COVID-19, those recommendations were communicated directly to the Nicaraguan authorities. Later, there were declarations to the effect that PAHO wasn’t issuing adequate recommendations. Of course, we included our comments in the press conference, and we sent our written response to those positions.

Protecting people is an essential part of controlling any public health emergency such as COVID-19.  So is the ability to implement actions so that people protect themselves from transmission. To do so, people need absolute knowledge of how it’s transmitted. This is a measure that all the countries have adopted.

Being able to detect the virus is an advantage of the stronger health systems.  To know where it’s being transmitted, and with what velocity. This also offers a public health advantage:

it protects the lives of the population. Not sharing that information clearly is a behavior that the PAHO rejects. We’ve said that several times.  It’s extremely important that the population knows where the virus is. When the systems for detection and processing are centralized, (…) the information is still more vital.

Of course, the circumstances around that high mortality point to the fact that the population didn’t take precautions. This means there’s a significant increase of cases in a short time that saturates the health services. Hence, they don’t have the capacity to save lives. Those deaths are due to such conditions.

We’re seeing now a tendency towards an increase of cases, but not the same increase in deaths. The data doesn’t follow the same rhythm, because the health services are now in better condition to receive those patients.

Decentralizing the taking of samples and the processing is an imperious necessity in all the countries. It’s one of the essential points in facing a risk like this one.

An evaluation mission to Nicaragua

In Nicaragua, the Coronavirus tests are all centrally processed in the “National Center for Diagnosis and Referral”. The government has never given out information on the results. Extra-officially, in August of this year, information came out about 17,000 tests that this laboratory had realized. [Note: to date, the estimate is 30,000]. The tendency was for 56% of these to be positive.  Can you conclude anything from this?

Nicaragua hasn’t given out any official information on the number of tests that have been performed. Effectively, we’ve received information from a number of sources, among them the one that you mention.  That information has been analyzed and included in the reports that are shared among all the countries.

The International Sanitary Regulations establish the World Health Organization and the PAHO as regional offices. As such, they not only have the responsibility, but also the obligation to seek all sources. They must use all these sources to perform an analysis of the situation in the countries. That’s so the States can adequately protect themselves.  It’s also so that the country that’s affected by an emergency can receive adequate timely information.

Nicaragua finds itself in the dark regarding the number of tests administered, or of positive COVID-19 cases and deaths.  However, there’s enough evidence to indicate that the authorities have engaged in a deliberate cover-up of the information. Can the PAHO realize an audit in the country, even if it hasn’t been officially requested by the government? Do you have the technical expertise and the authority to do this, given the emergency the country is living through?

We have the technical expertise, and we have the capability. Nonetheless, each country has the sovereignty to accept or not a mission for evaluation.  Nicaragua has signed the International Sanitary Regulations, which establish that countries should accept an analysis and evaluation mission. We hope that Nicaragua will accept that mission, because it would help the government, and above all the population. It’s a joint evaluation, it’s not an independent evaluation. That is, together we analyze the situation, we review and we reach conclusions.

The technical cooperation between the PAHO and Nicaragua continues in all other topics except that of COVID-19. It’s been a decision of the country we hope will change. I believe that with the current conditions, things are going nowhere.

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