The Perceived Consequences of Gold Mining in Postwar El Salvador: A Qualitative Study

Objectives. We investigated themes related to the health and environmental impacts of gold mining in El Salvador.Methods. Over a 1-month period in 2013, we conducted focus groups (n = 32 participants in total) and individual semistructured interviews (n = 11) with community leaders until we achieved thematic saturation. Data collection took place in 4 departments throughout the country. We used a combination of criterion-purposive and snowballing sampling techniques to identify participants.Results. Multiple themes emerged: (1) the fallacy of economic development; (2) critique of mining activities; (3) the creation of mining-related violence, with parallels to El Salvador''s civil war; and (4) solutions and alternatives to mining activity. Solutions involved the creation of cooperative microenterprises for sustainable economic growth, political empowerment within communities, and development of local participatory democracies.Conclusions. Gold mining in El Salvador is perceived as a significant environmental and public health threat. Local solutions may be applicable broadly.Mining activities raise significant public health concerns in the Americas and globally.1–3 Many countries in Central America have experienced increased mining activity by national and foreign corporations in the wake of trade agreement liberalization and erosion of environmental protections.4,5 This increase in mining activities has led to tension between mining corporations and local populations concerned with the health effects of mining.6 Nongovernmental organizations have begun to document such conflicts, which currently affect 19 countries from South to North America, with 191 ongoing mining conflicts.7 Case reports from other countries undergoing metal mining (e.g., gold, silver, and nickel) reveal significant health effects from mining. These range from hearing loss and mercury poisoning8 to elevated arsenic levels in the blood of local inhabitants.9Although these toxicological studies have delineated direct threats to health from metal mining, little if any research in Latin America has explored other detrimental effects on public health. In addition, the effects of mining in the historical context of civil war and foreign intervention in Latin America have not yet been explored. We therefore undertook a qualitative inquiry of a representative Latin American country, to explore attitudes about the public health ramifications of metal mining in a postwar context.El Salvador is unique in Latin America for historical and demographic reasons. The population of El Salvador experienced a civil war from 1980 to 1992. Up to 75 000 Salvadorans died (out of a population of 5.2 million), and a third of the population were internally displaced or fled the country.10 The civil war in El Salvador received extensive funding from foreign countries, primarily the United States, which contributed to the ongoing conflict and its associated deaths and disappearances among the local population.11,12 The mental health impact of the civil war is only now being understood.13El Salvador has among the highest population densities in the Western Hemisphere. Thus, the traumatic effects of disasters such as war, earthquakes, or environmental degradation have significant impact on large sectors of the population. Past exposure to such disasters—natural and manmade—have perhaps sensitized the population to the potential for extensive harm from future disasters.14 This has yet to be formally explored in a Salvadoran context.Since the end of the civil war in 1992, gold mining activities have increased in El Salvador, with public health concerns increasing in parallel. This may explain, in part, why local opinion polls reveal concern about mining activities. In 2007, the Instituto Universitario de Opinión Pública (University Institute of Public Opinion) of the Central American University conducted a poll among citizens living in metal-rich areas, typically in the north of the country. It found that 70% of Salvadorans opposed the initiation of a mining project in their community and felt this would have a detrimental impact on the lives of their children and grandchildren.15 Because limited data are available in the medical literature about the population health effects of mining specifically in El Salvador, it is unclear exactly how mining activity would be detrimental.Although the political, social, and historical context of El Salvador is unique in the region, many parallels exist with neighboring countries. We explored Salvadoran community leaders’ attitudes toward gold mining in a postwar context. We also wished to understand solutions and alternatives to mining that might be proposed by community leaders. Their attitudes, although specific to El Salvador, might be relevant to other countries in Latin America with a similar history and increases in mining-related conflict. The lessons learned from the experiences shared in El Salvador may therefore be relevant to countries beyond Central America.16     

U.S. Migrant Networks and Adult Cardiometabolic Health in El Salvador

Heightened prevalence of cardiometabolic health conditions in areas where infectious disease remains a major public health concern has created an especially challenging situation for developing countries, like El Salvador. Individuals living within migrant households where migrant networks are present may be at a greater risk for the development of cardiometabolic health conditions. Using data from the 2007 El Salvador database of the Latin American Migration Project (LAMP-ESLS4), this study investigates relations between financial remittances, familial U.S. migration history and cardiometabolic health conditions (overweight status, diabetes, hypertension, heart disease and stroke) among 534 individuals within 351 households from four different communities within the departments of La Unión, Cabañas, and San Miguel in El Salvador. Adults living in households that had close primary kin with U.S. migration history were almost two times less likely to be overweight (OR 0.456, p < 0.001) and obese (OR 0.453, p < 0.01) when adjusting for age, sex, education and economic well-being. This study highlights the importance of exploring the potential role of U.S. migrant ties in the epidemiologic transition present within developing countries, like El Salvador.     

Implementation of maternal influenza immunization in El Salvador: Experiences and lessons learned from a mixed-methods study

IntroductionThe World Health Organization (WHO) recommends that countries prioritize pregnant women for influenza vaccination, yet few low- or middle-income countries (LMICs) have implemented maternal influenza immunization programs. To inform vaccine decision-making and operational planning in LMICs, there is a need to document and share experiences from countries that provide seasonal influenza vaccine to pregnant women, particularly those with high coverage, like El Salvador.MethodsIn 2015 and 2016, PATH and country researchers conducted a mixed-methods study to document the experience and lessons learned from maternal influenza immunization delivery and acceptance in El Salvador as part of a collaborative effort between WHO and PATH. Researchers conducted focus group discussions, semi-structured interviews, antenatal clinic exit interviews, and key informant interviews with 326 participants from two municipalities in each of the country’s three regions. Respondents included pregnant and recently pregnant women, family members, community leaders, health personnel, public health managers and partners, and policymakers.ResultsFactors perceived as positively influencing maternal influenza immunization delivery and acceptance in El Salvador include the use of multiple vaccine delivery strategies, targeted education and community engagement efforts, and a high degree of trust between the community and health care providers. Influenza vaccine acceptance by pregnant women is high and has improved over time, largely attributed to education targeting health care advisors. Perceived challenges to pregnant women receiving health care and vaccination include the need for permission to attend services and limited access to health services in insecure areas related to the presence of criminal gang activity.ConclusionsWe identified approaches and barriers perceived to affect maternal influenza vaccine delivery in El Salvador. This information will be useful to public health decision-makers and implementers in El Salvador and other countries considering introduction of new maternal vaccines or striving to increase coverage of vaccines currently provided.     

Mental health systems in El Salvador, Guatemala, and Nicaragua: results of a WHO-AIMS evaluation]

The authors evaluated the mental health systems of El Salvador, Guatemala, and Nicaragua, using a group of select indicators. The World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS) was used to collect data from the nations. The national mental health systems of Nicaragua, Guatemala, and El Salvador have serious limitations, especially in primary care, and a marked lack of qualified human resources. Budget allocations for mental health care are barely 1% of the total health care budgets; and the psychiatric hospitals located in the national capitals consume at least 90% of those funds. The limited human and material resources available are concentrated in the respective country capital cities. National mental health policies and legislation have not been adopted; however, all three countries do have national plans in progress. Furthermore, all three have designed and implemented programs for mental health care in case of disaster. Agreements must be reached with offices for the defense of human rights to raise awareness and protection of rights for the mentally ill. In recent years, new experiences have been gained and these should be distributed more widely. The Pan American Health Organization (PAHO/WHO) and the WHO-AIMS project have contributed toward developing community models for mental health services. Lastly, priorities have been identified and action items recommended.     

Disaster preparedness. Ready for earth, air, fire and water (and who knows what else)?

Already the 1990s might be described as a decade of disasters: From the devastation of hurricanes on the East Coast to the havoc of floods in the Midwest to the destruction of earthquakes and civil unrest on the West Coast, the past few years clearly show that disasters can strike anywhere--and at any time. For health facilities caught in the middle of these crises, emergency preparedness means much more than just meeting the basic requirements of the Joint Commission on Accreditation of Healthcare Organizations or complying with state and local regulations. Rather, for most health facilities, preparing for disasters is an integral part of ensuring that they can continue to provide adequate, high-quality patient care under almost any circumstances. This report, the first in a series of articles, examines how health facility managers coped once they found themselves in the midst of major disasters, what lessons they learned about emergency preparedness as a result of their experiences, and what others can learn from these difficult situations.     

'There is no sea, only fish': effects of United States policy on the health of the displaced in El Salvador

The poor health status of El Salvador's displaced is a direct result of government policy which defines civilians as legitimate military targets. The effects of this 'strategic hamlet' policy on health is vividly seen in five areas of concern: war related trauma, infectious diseases, malnutrition and insufficient health services due to the repression of health providers and lack of resources. This report documents the major causes of mortality and morbidity among the 500,000 displaced in El Salvador and discusses the efforts of government and private organizations to meet their health needs. Health services for the displaced are primarily provided by private voluntary organizations which base their work on active neutrality. However, neutrality has become almost as dangerous as active opposition. The active repression of health workers by government security forces has exacerbated the already severe shortage of health care services for the displaced.     

Dimensions of child punishment in two Central American countries: Guatemala and El Salvador.

OBJECTIVE: Severe physical punishment of children is an important issue in international child health and welfare. This study examines such punishment in Guatemala and El Salvador. METHODS: Data came from nationally representative surveys of women aged 15-49 and men aged 15-59 residing in Guatemala (2002) and El Salvador (2002-2003). The surveys included questions about punishment experienced during childhood, with response options ranging from verbal scolding to beating. In Guatemala, parents were asked how they disciplined their children; questions allowed them to compare how they were punished in their childhood with how they punished their own children. Bivariate and multivariate analyses are presented. RESULTS: In Guatemala, 35% of women and 46% of men reported being beaten as punishment in childhood; in El Salvador, the figures were 42% and 62%, respectively. In both countries, older participants were relatively more likely than younger participants to have been beaten as children. Witnessing familial violence was associated with an increased risk of being beaten in childhood. In Guatemala, having experienced physical punishment as a child increased the chance that parents would use physical punishment on their own children. Multivariate analyses revealed that women who were beaten in childhood were significantly more likely in both countries to be in a violent relationship. CONCLUSIONS: The use of beating to physically punish children is a common problem in Guatemala and El Salvador, with generational and intergenerational effects. Its negative and lingering effects necessitate the introduction of policies and programs to decrease this behavior.     

Primary health care in practice: is it effective?

Primary health care is accepted as the model for delivering basic health care to low income populations in developing countries. Using El Salvador as a case study, the paper draws on three data sets and a qualitative survey to assess health care access and utilization across public and private sector options (including NGOs). Multivariate analysis is used to estimate the quantitative determinants of health seeking behavior. Physical and financial access is generally good. Households do not value the community health workers, and prefer high cost private care, even the poorest families, because of the lower waiting times and higher probability of successful treatment. Similarly, higher level public facilities--health centers and hospitals--are preferred because they are less costly in terms of time as they offer "one stop shopping" and do not require multiple visits, and treatment success is higher than among health posts, health units or community health workers. These results combined with the small size of El Salvador suggest that alternative strategies to community health workers may be a more cost effective approach. While prevention is desirable, community health workers do not have the skills or services that the communities value, which makes them less effective in promoting prevention. Alternative modes of reaching the community could reduce costs and raise the effectiveness of public health spending.     

Who benefits from health programs aimed at the poorest? Successes and failures. 2008 SESPAS Report

International aid health programs directed at the poorest play an undoubtedly constructive role in relieving acute human suffering. These programs may, however, be counterproductive and even harmful if they obscure the need to eliminate social inequities, which are the primary cause of health inequities. The present article reviews the effectiveness of two state programs that received support from international aid to (a) improve food security in rural households and vulnerable urban groups in Colombia (1996-2005) and (b) develop a local health system in the northern area of San Salvador, El Salvador (1992-1997). International aid supports successful healthcare programs, such as food programs, could generate dependency in its beneficiaries. Factors extrinsic to cooperation (political and economic factors of the context) may affect the programs and generate social conflicts. This is the case of the program to improve access to food by subsistence production in rural areas of Colombia, which failed to reach the small farmers and benefited agricultural export production owned by wealthier groups, or interventions designed to improve health among the poorest in El Salvador.     

Attitude toward the risk of epidemics during sudden disasters (author's transl)

Following sudden disasters, major outbreaks are rare unless malnutrition and starvation are common. No dramatic increase of water borne diseases has been reported and adequately documented in the aftermath of the earthquakes, cyclones or floods of this decade. However, the attitude of the public, the mass media and of the health services is sometimes irrational leading to impressive but ineffective mass immunizations. An epidemiologic system and accurate information on the actual situation are essential in case of major disasters.     

Results of nutritional status surveillance in El Salvador, 1975 - 77

Nutritional status surveillance data based on the clinical diagnosis of malnutrition and on weight-for-age, as well as diarrhoeal disease data for preschool age children attending government health clinics in El Salvador are presented for a 3-year period (1975 - 77). Surveillance results indicated consistently higher rates of clinical malnutrition and weight-for-age deficit in rural children as compared with urban children, and higher malnutrition rates in children 1 - 4 years of age as compared with infants less than 1 year old. Consistent seasonal increases in malnutrition were observed that were most pronounced in older preschool children (1 - 4 years) in rural areas. Seasonal peaks in malnutrition consistently followed 1 - 2 months after the major seasonal peak in diarrhoea at the onset of the rainy season, suggesting that diarrhoea may play a role in the etiology of malnutrition. A secondary seasonal peak in diarrhoea in the cooler, dry season was most prominent in infants but was not related to increased malnutrition. These results indicate that nutritional and health status indicators formed from data collected regularly at health centres can demonstrate consistent age group, urban/rural, and seasonal differences in nutritional status that may be useful in identifying risk groups and in monitoring nutritional changes for planning and evaluation purposes.     

Rapid assessment of health needs in mass emergencies: review of current concepts and methods

The increase in the number of natural disasters and their impact on population is of growing concern to countries at risk and agencies involved in health and humanitarian action. The numbers of persons killed or disabled as a result of earthquakes, cyclones, floods and famines have reached record levels in the last decade. Population density, rampant urbanization and climatic changes have brought about risk patterns that are exposing larger and larger sections of populations in developing countries to life-threatening natural disasters. Despite substantial spending on emergency relief, the approaches to relief remain largely ad hoc and amateurish, resulting generally in inappropriate and/or delayed action. In recent years, mass emergencies of the kind experienced in Bangladesh or the Sahelian countries have highlighted the importance of rapid assessment of health needs for better allocation of resources and relief management. As a result, the development of techniques for rapid assessment of health needs has been identified as a priority for effective emergency action. This article sketches the health context of disasters in terms of mortality and morbidity patterns; it describes initial assessment techniques currently used and their methodological biases and constraints; it also discusses assessment needs which vary between different types of disasters and the time frame within which assessments are undertaken. Earthquakes, cyclones, famines, epidemics or refugees all have specific risk profiles and emergency conditions which differ for each situation. Vulnerability to mortality changes according to age and occupation, for earthquakes and famines. These risk factors then have significant implications for the design of rapid assessment protocols and checklists. Experiences from the field in rapid survey techniques and estimation of death rates are discussed, with emphasis on the need for a reliable denominator even for the roughest assessment. Finally, the importance of adapting normal epidemiological and statistical methodologies to crisis situations is underlined in order to rationalize the recurrent and substantial expenditures made in response to natural disasters today.     

Evaluation of a programme to train village health workers in El Salvador

The civil war in El Salvador has had devastating effects onthe country's health care system, especially in rural areas.The Catholic Archdiocese of San Salvador undertook a programmeto train village health promoters, in an effort to alleviatethe serious shortage of primary health care in some of the affectedareas. The objectives of the programme included not merely anattempt to take medical care to the most needy, but rather thepromotion of health education and community development. Thevolunteer promoters received a four-week training course. A private non-profit international organization, AesculapiusInternational Medicine, took over the follow-up and supervisionof a group of promoters in 1984. One part of the programme evaluationwas a survey designed to assess the work patterns and attitudesof the promoters. It was found that most of them spent a greatdeal of time treating illnesses and very little on communityhealth education. As a result, a one-week course devoted tocommunity education was added to the curriculum and emphasiswas placed on increasing teaching skills and confidence.     

Immunization campaigns and political agendas: retrospective from Ecuador and El Salvador.

Since the mid-1980s international donors have promoted vertical, campaign-based strategies to help improve immunization coverage in poor countries. National immunization days (NIDs) are currently in vogue and are prominent in the worldwide polio eradication efforts. In spite of their widespread use, campaigns that include NIDs have not been well evaluated for their effects on coverage, reduction in vaccine-preventable diseases, or effects on the health system. An assessment of the results of two such campaigns implemented in Ecuador and El Salvador shows limited impact on short-term coverage and questionable effects on long-term coverage and disease incidence. Although NIDs may have substantial short-term political benefits, the vertical approach can undermine provision of routine services by ministries of health and may be counterproductive in the long-term.     

Disasters and public health.

Studies on the health effects of disasters have shown that epidemiological indices can be of value in planning preventive and relief measures and in evaluating their effectiveness. Mortality rates naturally vary considerably, but in earthquakes, for example, the number of deaths per 100 houses destroyed can give an indication of the adequacy of building techniques. Age-specific mortality rates can help to identify particularly vulnerable groups and perhaps indicate what form of education would be valuable. Except in earthquakes, the number of casualties after a disaster is usually low in relation to the number of deaths, and study of the distribution and types of lesions would help in planning the amounts and types of relief supplies and personnel required. Disasters also affect the general level of morbidity in a district because of either interruption of normal health care services or of spraying or other disease control measures. Mental health and nutrition following disasters are particular problems that require further investigation. Study of all these features of disasters has been handicapped by a lack of data, particularly concerning the health situation immediately after the impact. The provision of surveillance teams in disaster-prone areas would appear to be a field in which international cooperation could yield immense benefits.     

The impact of health-management training programs in Latin America on job performance

A study was undertaken in Mexico, Colombia, and El Salvador to determine the impact of a management training program on health managers' job performance. A quasi-experimental design was used where in the baseline study an intervention group of 85 district health managers in the three countries was compared with a control group of 71 managers who did not receive the training program. After the implementation of an 18-month training program (which included 5-day training workshops and a series of tasks to be carried out between the workshops), the outcome in terms of improved job performance (i.e. use of predefined management techniques) was measured through twelve management performance indicators. The data collection tools were two questionnaires, participant observation in managers' workplaces, focus group discussions, staff interviews, and document analysis. In Mexico, the control group showed 8.3 times weaker management performance compared to the intervention group; in Colombia the value was 3.6 and in El Salvador 2.4. Factors associated with a successful training outcome were: (a) training techniques, (b) strengthening of enabling factors, and (c) reinforcement mechanisms.     

A cross-national comparison of youth risk behaviors in Latino secondary school students living in El Salvador and the USA

Objectives. As Latin Americans’ exposure to the USA increases through migration patterns and US political and economic ties to their countries of origin, they become susceptible to adopting not only the cultural expressions of the USA such as fashion, but also the health-related behaviors of the US population. In assessing potential health risks for Salvadoran youth that may result from the connection between Latin Americans and the USA, this study compared the prevalence of health risk behaviors from four behavior domains (aggression and victimization, depression and suicidal ideation, substance use, and sexual behavior) between Salvadoran and US Latino secondary school students aged 14–17 years.

Design. A secondary analysis was performed on two 1999 cross-sectional survey data. In the USA, results were based on 1,063 Latino high school students who answered the nationally representative Youth Risk Behavior Survey (YRBS) conducted by the Centers for Disease Control and Prevention. In El Salvador, results were based on 793 public secondary school students who answered a local YRBS survey conducted in coordination with the Ministry of Education of El Salvador.

Results. The prevalence rates for aggression/victimization and for depression and suicidal ideation behaviors were similar between Salvadoran and US Latino adolescents. Substance use prevalence, however, was 10–40% higher for US Latino adolescents. While the prevalence of sexual intercourse was higher among US Latino youth (between 13 and 27% higher, depending on age), the prevalence of condom use was lower among sexually active Salvadoran youth (between 11 and 42% lower, depending on age).

Conclusions. In the context of the transnationalization of the Salvadoran population, with potential for increased influence of the USA in Salvadoran culture, these differences in risk behavior are important for targeting effective interventions for Latino adolescents in El Salvador and in the USA.     

Neoliberal health sector reforms in Latin America: unprepared managers and unhappy workers]

This work analyzes the neoliberal health sector reforms that have taken place in Latin America, the preparation of health care workers for the reforms, the reforms' impacts on the workers, and the consequences that the reforms have had on efficiency and quality in the health sector. The piece also looks at the process of formulating and implementing the reforms. The piece utilizes secondary sources and in-depth interviews with health sector managers in Bolivia, Colombia, Costa Rica, the Dominican Republic, Ecuador, El Salvador, and Mexico. Neoliberal reforms have not solved the human resources problems that health sector evaluations and academic studies had identified as the leading causes of health system inefficiency and low-quality services that existed before the reforms. The reforms worsened the situation by putting new pressures on health personnel, in terms of both the lack of necessary training to face the challenges that came with the reforms and efforts to take away from workers the rights and benefits that they had gained during years of struggles by unions, and to replace them with temporary contracts, reduced job security, and lower benefits. The secrecy with which the reforms were developed and applied made workers even more unified. In response, unions opposed the reforms, and in some countries they were able to delay the reforms. The neoliberal reforms have not improved the efficiency or quality of health systems in Latin America despite the resources that have been invested. Nor have the neoliberal reforms supported specific changes that have been applied in the public sector and that have demonstrated their ability to solve important health problems. These specific changes have produced better results than the neoliberal reforms, and at a lower cost.     

Will your IT system be ready when disaster hits?

This year's series of tornadoes, hurricanes, earthquakes and other natural disasters sent shivers down the spines of hospital and health information technology leaders. Most wired hospitals have safeguards in place so systems can be restored quickly.     

Psychosocial impact of violence in San Salvador]

This study had two objectives: (1) to describe the levels of victimization of Salvadorians due to criminal violence, and the population groups most affected by it; (2) to learn if these levels of victimization are related to the presence of norms, attitudes, and behaviors that encourage the occurrence of violence. For this purpose data from the ACTIVA project of El Salvador were used. The project was carried out by the University Institute of Public Opinion during October and November 1996, with a sample of 1,290 personal interviews that were presumed to be representative of people between 18 and 70 years of age living in the Metropolitan Area of San Salvador. The sample was obtained through multistage probability sampling. The results show that the level of victimization from violence is quite high in San Salvador and that it especially affects adult and young men. The results also indicate that persons who have been victims of serious aggression tend to show, more frequently than average, norms justifying and approving the use of violence, a tendency to use weapons, and aggressive behaviors toward other people.