‘Prison, economic ruin, repression and exile’: the price Nicaragua’s health workers pay for doing their jobs

One morning in August 2014, Dr. Richard Saenz Coen received a phone call from Nicaragua’s Minister of Health. She needed a highly qualified gynecologist to perform a caesarian on a woman in labor, immediately. Dr. Saenz was escorted to a public hospital and found the premises practically empty, closed off by security forces and police. When he arrived at the operating room, he was shocked to find it occupied by armed paramilitaries. A man in plain clothes grabbed the doctor’s hand, and told him in a threatening tone, “you better know what you’re getting yourself into.” 

A couple of hours later, Nicaragua’s president, Daniel Ortega, and his wife, the current vice president Rosario Murillo, appeared outside the operating room. Dr. Saenz had just delivered their grandchild. President Ortega shook his hand and thanked him for his service. Dr. Saenz could have never predicted that just a few years later this very same president – himself a torture survivor and revolutionary during the Sandinista uprising against the Somoza dictatorship in the 1970s – would oversee the dismissal, imprisonment, torture and exile of him and his fellow health workers.

Dr. Saenz fled Nicaragua in June 2021. “Prison, economic ruin, repression, and now exile” were the prices he paid for being a doctor in Nicaragua, he told Amnesty International. He is one of almost 200 doctors who have fled Nicaragua since 2018, and, according to the Inter American Commission on Human Rights, one of more than 400 doctors dismissed from their jobs. And with COVID-19 cases reaching alarming levels and presidential elections looming in November, the context could not be grimmer for Nicaragua’s health workers.

The nation has been mired in a grave human rights crisis since April 2018, when hundreds of people took to the streets to protest social security reforms in Nicaragua. The Ortega government responded with an unprecedented wave of repression and crackdown on dissidents that continues to this day. More than 100,000 people have fled the country in this time, while dozens of activists, human rights defenders and journalists have been threatened, imprisoned, tortured, and in some cases disappeared. The authorities have intensified their repressive tactics with a new wave of arrests in the lead up to elections, detaining more than 30 people simply for exercising their human rights since 28 May 2021.

Doctors like Saenz who dare to practice their profession against the will of the government are at grave risk in this context. He is one of dozens of doctors who took to the streets in 2018 to attend to the protestors that sustained bullet wounds and injuries during the crackdowns. Under government orders, public hospitals refused to attend to those injured, so doctors gave up their own time to treat them.

In the months following the April 2018 protests, Dr. Saenz was again summoned by the Ministry of Health. This time it was not to receive any gratitude nor handshakes for serving his people. Without any judicial order, the authorities told him his medical license would be revoked immediately and that he was prohibited from practicing medicine in the country.

The persecution against him did not end there. The Nicaraguan police detained Dr. Saenz four times over the next three years. On most of these occasions the authorities held him for several days, beat him and deprived him of food. In one instance, they took him to El Chipote, a police facility in Managua infamous for the brutal treatment detainees face there.

“My time in detention was degrading and humiliating. There was so much abuse. They beat me, they kicked me, they forced me to watch people being raped in front of me. There are other things that happened that I don’t even want to remember,” Dr Saenz told Amnesty International.

During these years, Dr. Saenz maintained a low profile and secretly continued to treat patients as well as carrying out charity work that he had been doing for many years. He was not only a doctor but also owned a small dairy farm and a shrimp business. However, the government ensured that all his assets dried up. By the time he decided to leave Nicaragua, pro-government groups had raided his house and destroyed and stolen his possessions. According to Dr. Saenz, the authorities used his stolen documents to fabricate charges of social security fraud against him.

Despite the relentless persecution he faced, in 2020 Dr. Saenz participated in a volunteer drive to bring medical supplies to indigenous communities affected by COVID-19, as well as providing medical care for dissidents and political prisoners who later fled the country. His actions angered the authorities, who followed him and detained him again for four days in April 2021 in the Chinandega police station.  He fell ill due to his preexisting condition of diabetes and insulin dependency, and after days of near starvation, ill treatment, and interrogation, the police set him free.

Yet the threats and persecution against him did not abate. In June 2021 a trusted source told Dr. Saenz the authorities were coming for him again, this time with no mercy. It was time for him to flee the country.

Hundreds of doctors and nurses across Nicaragua have suffered similar experiences. For many, their only “offense” was following science and upholding the duties of their profession.

Since the World Health Organization declared COVID-19 a pandemic in late March 2020, the Nicaraguan authorities tried to downplay its impact in the country. They promoted mass public gatherings and kept schools open. Health workers told Amnesty International they were initially prohibited from wearing personal protective equipment (PPE) at work, and some had their masks forcibly stripped from their faces. Others suffered reprisals at work for diagnosing patients with COVID-19. The authorities argued that they did not want to generate “panic” among the population.

“In my mind, it’s easier for this government to have you die from COVID-19 than have to kill you by gunfire,” one doctor, speaking on condition of anonymity, told Amnesty International. “For me, the government’s approach to COVID-19 has amounted to collective murder.”

In May 2020, over 700 doctors signed a letter addressed to the Nicaraguan government, urging it to consider the science on COVID-19 and urgently implement a series of public health measures. Soon after, dozens were fired in reprisal for speaking out and signing the letter. When Amnesty International asked them about the circumstances of their dismissal, they said hospital directors simply told them they were being fired due to “higher orders”, and gave no other reasons.

“These medical personnel were like a lighthouse in the middle of the dark,” said Nicaraguan journalist Wilfredo Miranda.

Dismissals were not the only consequences they faced. Along with Dr. Saenz, several other doctors have been followed by government informants, slandered in the media, or surveilled daily by police outside their residences.

According to the Citizen Observatory on COVID-19 in Nicaragua, an independent collective set up to pool data and information on the pandemic, 155 health workers have died from the virus. Yet Nicaragua’s Ministry of Health has not provided any public data on infection rates nor deaths of health workers during the entire pandemic.

In late July, the Ministry of Health summoned several doctors to its offices and told them that if they did not stop disseminating information about the pandemic, they could face arrest or prison under the new Special Law on Cybercrimes. Passed in December 2020, the law establishes a legal framework that can be used to convict anyone expressing an opinion that, in the eyes of the authorities, “causes alarm, fear or anxiety”.

In the following days, the government passed a decree to cancel the legal registration of 24 civil associations, many of them medical organizations. The authorities’ pretext for this decree was that many organizations did not have their papers in order. However, representatives of associations told Amnesty International that, since 2018, the government had made it impossible to keep registries up to date.

“The government began to invent administrative excuses to keep your organization in legal limbo, so that it became impossible to have your registries up to date, even though you had presented all the papers as requested,” said one founding member of a community medical organization.

One representative of an organization that provides health to communities in vulnerable situations throughout the country told Amnesty International that the police turned up without a warrant and began to seize the organization’s property. This was before the decree had even become official. More than a dozen staff members instantly lost their jobs.

The bureaucratic assault on these organizations followed the silencing of other important voices in Nicaragua’s medical community. During the 2018 repression, a series of collectives and doctors’ organizations were founded, including the Nicaraguan Medical Unit (UMN). With the arrival of the COVID-19 pandemic, the UMN took on a prominent role in providing reliable information to the public. But, amidst the government crackdown on the medical sector, the UMN was forced to close its premises and disband in late June 2021.

One UMN member spoke to Amnesty International from exile, having fled the country in June. He said that two members of pro-government armed groups on motorbikes had followed him as he left his house for his medical clinic one morning. “That’s the modus operandi of how they work. First the paramilitaries locate you and follow you, and then they inform the police who come for you shortly afterwards to arrest you.” The doctor fled the city immediately. In the following days his house was under constant police surveillance.

Dozens of other Nicaraguan health workers have also sought asylum in the United States, Costa Rica and other Central American countries.

As if the tactics of repression, harrassment and legal cancellation were not enough, health workers have also been overlooked in Nicaragua’s vaccination efforts. The first batch of vaccines arrived on 24 February 2021, donated from Russia in an unspecified amount, followed by donations of the AstraZeneca vaccine from the WHO’s COVAX facility in March, further donations from Russia in May, and most recently a second shipment of COVAX-provided vaccines in early August.

The WHO has called for health workers, especially those exposed to COVID-19, to be prioritized in any country’s vaccine rollout, as well as calling on states to publish a clear plan that outlines the priority groups for vaccination. Yet Nicaragua commenced its vaccination by completely ignoring health workers, who only started receiving shots in May 2021, long after others had received theirs.

A doctor responsible for coordinating Nicaragua’s vaccination programme during the 1980s told Amnesty International the country has the capacity to vaccinate at least 150,000 people per day. The current effort pales in comparison. “This is the worst vaccination effort I have seen in more than 40 years working in the health sector in Nicaragua,” he said. Nicaragua has one of the lowest vaccination rates of any Latin American country, with just 5.4% of the population fully vaccinated as of mid-August .

There are no public details on who has been vaccinated and under what criteria. A handful of doctors and nurses have been vaccinated in some hospitals, but others are still waiting. Amnesty International tried to obtain information about access for maintenance personnel and cleaners in hospitals, without any luck. Some media reports have pointed to favoritism in vaccinating government supporters first, regardless of their risk profile for COVID-19.

One doctor currently living in exile in Guatemala told Amnesty International of the pain of losing one of her closest friends and colleagues to COVID-19 as recently as June, when the government could have vaccinated health workers much earlier.

The Ministry of Health’s role in putting health workers’ lives at risk has even led to individual sanctions by the US government. In 2019, the US Treasury Department placed individual sanctions on the assets of Sonia Castro González – the Health Minister who called Dr. Saenz to deliver Ortega’s grandchild in 2014 and who remains in office to date. The US government said it designated her for “leading the Ministry of Health, an entity that has, or whose members have, engaged in significant human rights abuse violations.”

For his part, Dr. Saenz is still searching for a haven outside of Nicaragua.

“What I have lived is a horror in silence. I can’t take it anymore. I remained silent and was persecuted for it. It’s time for me to speak up.”