According to the World Bank, more than 720,000 people in El Salvador (12% of the population) suffer from chronic kidney disease. In 2020 more than a million people stopped receiving their outpatient treatments and medications because the health system overturned all your attention to the health emergency caused by Covid -19.
By Nancy Hernandez and Omar Martinez
Las Mesas, El Salvador.
Angelica de Jesus Perez is 41 years old. For years she was diagnosed with diabetes and in 2020 it was difficult for her to keep her regular check-up because the entire health system in El Salvador focused on caring for patients with covid-19 and consultations were suspended.
With mandatory confinement and the first two waves of contagion in the country, the economic, social and psychological impacts were present in all social sectors.
The uncertainty and fear of the virus grew in the population, the government authorities turned their attention to attending to the health emergency to protect the health of Salvadorans; however, they neglected the well-being of thousands of people because the public health system stopped treating patients with chronic diseases, suspending surgeries and check-ups.
Panorama of a silent crisis
In El Salvador by 2020 there were 1,858,414 people who needed secular treatments and controls, according to the 2019 National Policy document for the Comprehensive Approach to Non-communicable Diseases of the Ministry of Health (Minsal). Most of these people stopped receiving care during the confinement period, between March and August of that year.
2020 closed with 1,336 deaths from covid-19, according to official data from the Government of El Salvador. However, until September of that year, 5,600 people died from cancer and 1,404 more from diabetes, kidney failure, liver disease and hypertension, which fall into the category of chronic diseases, as detailed in the document Main causes of mortality that occurred in the Network of Hospitals of the Minsal of 2020.
Angélica Pérez is a 41-year-old Salvadoran woman who suffered firsthand from not being treated by the health system for her diabetes for a year. Photo: Nancy Hernandez
This situation endangered Angélica’s health, who must follow check-ups every month and permanently consume diabetes medications. She lives in the Las Mesas community, located 40 kilometers from San Salvador, the capital. It is a rural area, difficult to access and where most families live from agriculture.
In the settlement, twelve other people, including his father, Julio Pérez, were diagnosed with kidney failure and suffer from chronic illnesses. They all lost control.
“Many people here suffer from chronic diseases such as sugar, kidney failure; many people missed their appointments; that is why today they took longer and in that quarantine period it is difficult to go to the health unit,” he explained.
On the night of March 21, President Nayib Bukele announced on the national network the mandatory quarantine for 15 days. Those two weeks were prolonged in distressing three months of confinement in a state of emergency and exception between March 14 and June 14.
Salvadoran families, through Executive Decree No. 12 of the Ministry of Health, lost constitutional guarantees such as free movement and freedom of assembly. El Salvador officially registered the first case of covid on March 19, 2020.
In this context, Silvia Juárez from the Organization of Salvadoran Women for Peace (ORMUSA), explained that the collapse of health services around the pandemic affected and decreased «the quality of life of people who suffer from chronic diseases.»
Among these, warns the specialist, are women with cancer, kidney failure; those with early detection of cervical cancer, breast cancer, and those who have interrupted all their processes.
“A year after the health conditions appear and begin to normalize, these conditions are already clearly advanced and their risk of death has increased; that is, it is almost mathematical that deaths could occur due to conditions, given the precarious conditions. In which the health system was abandoned and that quality care was not possible during confinement, ”says the specialist.
Similarly, the epidemiologist Jorge Panameño points out that there were hundreds of Salvadorans affected and to date, the impacts or number of deaths caused by this measure are unknown.
“I think that attention is already restored at this time. But what happened at the time of the quarantine; what consequences were paid in the two years of the peak period of the 2020 pandemic and the first months of 2021; what happened, what? It has been the impact, we don’t know all that. There is no information,» he said.
The drama of the sick in El Salvador
Julio Pérez, Angélica’s father, has suffered from kidney failure for a decade, in confinement his treatments were suspended as well as medications. It was not possible for him to continue with his controls due to the suspension and because due to the quarantine there was no public transport to get to the health center.
In the case of people with kidney failure, some managed to receive dialysis and hemodialysis treatments. But they did not have a safe place, and this meant exposing themselves even more to contracting covid-19, because their immune system is vulnerable to the disease itself.
The study «Mortality due to COVID-19 associated with comorbidities in patients of the Salvadoran Social Security Institute», published in 2021 by the Ministry of Health, indicates that of 2,670 patients with chronic diseases who were treated in the hospitals of the Salvadoran Social Security Institute (ISSS) enabled to care for patients with the virus, 1,234 died, that is, 46.2 percent.
Of these, according to the article, 87 percent occurred in patients who were in hospitalization services; 69.8 percent were men; 50.7 percent (626) were aged between 40 and 59 years.
Chronic diseases with more mortality
The population that died and suffered from other chronic health conditions was distributed as follows: high blood pressure 28.5% (352) and diabetes mellitus 24.6% (304). The highest specific mortality, according to pre-existing condition, occurred in those patients with liver cirrhosis, of whom 23 of the 25 cirrhotics detected in the screening (92%) died, followed by patients with cancer (81.8%), diabetics (77.7%), hypertensive (77.4%), chronic heart disease (76%) and kidney disease (71.8%).
“Chronic diseases that, as part of their evolution, alter defense mechanisms and maintain a chronic proinflammatory state were associated with higher mortality (…) diabetes mellitus, high blood pressure, chronic kidney failure, heart disease, chronic lung disease, obesity, cancer and liver cirrhosis are related to higher mortality and lower survival”, concludes the study.
The violated rights
The Ombudsman for the Defense of Human Rights in the report. Deficiencies of the National Integrated Health System in the context of the covid-19 pandemic, detailed that the institution received 393 complaints related to the “denial of medical care and denial of covid-19 tests. 19 and due to the lack of attention to other diseases and treatments as a side effect”
The Pérez and an estimated 30 other families that make up the Las Mesas community, in the municipality of La Libertad, in the homonymous department, are an example of the ordeal experienced by Salvadorans during this unprecedented period of humanity in the last century.
Unlike Las Mesas, where its inhabitants did not mourn the virus, in the Central American country thousands of families lost their loved ones. Until October 17, 2022, El Salvador registered a total of 201,785 confirmed cases on the official page www.covid19.gob.sv, of which there were 4,230 deaths, 18,145 active cases and 179,410 people recovered from covid-19.
“The most there were in the community were four infections. Thank God here in the community there has been no death, «said Angélica about it.
According to government data, 50.3 percent of confirmed cases were women, while 49.7 percent were men with ages ranging from 20 to 39 years and 40 to 59 years.
Isolation and without resources
The families of Las Mesas were isolated when the state of emergency declared by the Government prevented free movement and many Salvadorans were taken to containment centers for violating the mandatory quarantine.
This led people to stay at home with the resources they had; in the case of the inhabitants of the community they were limited to basic grains, since even in the stores there was a shortage of products.
Patients with chronic illnesses like Angélica and her father were also forced to stay at home.
“We are families that dedicate ourselves to agriculture, corn, and beans. Thank God these products were available, but as always, additional things like oil, other issues like tomatoes, chicks, that was the difficult thing we faced, «said Angélica
However, the organization of neighbors and solidarity contributed to reducing the risk of a collective famine.
“For us, during the quarantine period it was very difficult because it was forbidden to go out to town, so the people who had a store no longer went to buy, food was scarce, and then what was done was that a police officer was called. Pick up, since you couldn’t leave because of the confinement, what the family did is that one person would go and bring food to up to three or four families because since the car couldn’t go full because the soldiers and the police were outside if they saw that, they stopped the car,” Angélica recounted.
The other drawbacks
Every day Angélica walks with a pitcher in her hand to a spring that is near her house.
You must guarantee the liquid to be able to wash clothes, dishes, cook and others. Another of the major drawbacks of this community was access to drinking water, because since its foundation, 35 years ago, they do not have the service and are supplied with rainwater, river and spring.
The lack of the liquid made them more vulnerable to the disease because frequent hand washing was not an option, despite the fact that the World Health Organization (WHO) recommended the action as one of the main measures to avoid coronavirus infections.
The mother of three daughters assures that during the months of the pandemic she had to reinforce her efforts to draw water and instead of making one or two trips a day, she made six or ten trips.
Once again, it was the women who had to procure water in each home.
“We are a community that does not have water and all of this affects us because we women have to go around seeing that the water is there. (In quarantine) we redoubled our work because we had to pull more water for the same problem, because more was needed to wash your hands or when you went out to bathe, wash clothes and take precautionary measures to avoid contagion, we It complicated a lot with the water, too,» he said.
Due to the lack of economic resources, the families could not buy gel to disinfect their hands either; instead, they bought liquid alcohol. Currently the masks are sold in the store, but at that time they had them made of cloth to protect themselves.
Despite the limitations, the measures worked because there were no deaths from covid-19 and infections did not exceed a dozen.
One of the main recommendations of the government and those during the pandemic was to maintain hygiene with hand washing. but the families of the Las Mesas community did not have water for their chores. Photo: Nancy Hernandez.
Official data on covid-19 in El Salvador
The data from the site also shows that the department most affected by the virus is San Salvador, which to date registers 56,826 cases of Covid, followed by La Libertad with 21,282; in third place is the western department of Santa Ana with 18,407; the fourth with the most cases is San Miguel, located in the east of the country, with 16,864 cases of Covid.
It should be noted that the aforementioned departments are the most populous of the three geographical areas into which the country is divided: West, Center, and East.
The first peak of the pandemic was during the months of June and August 2020; in fact, on August 9 there were 449 confirmed cases, but the trend began to reduce until reaching 98 confirmed infections per day on the 29th of the same month, date on which the first wave can be considered to have ended.
However, one cannot speak of epidemiological silence or zero infections, only maximum peaks or sustained increases until they steadily decline, according to the statistical bulletin, Evolution of Covid19 cases in El Salvador, from March 14, 2020 to August 1 of 2021 of the Dr. Guillermo Manuel Ungo Foundation (FUNDAUNGO).
So far, the statistics mentioned correspond to official government data, which have been questioned since the start of the pandemic by health organizations, civil society and even international institutions, which is why it is necessary to talk about the underreporting of infections and deaths.
Underreporting contradicts official data
Angélica says that she was very scared to see so many deaths from Covid-19 and her concern grew even more when two of her brothers were infected and were about to be hospitalized due to fatigue and difficulty breathing. In addition, his condition represented a double risk.
«One of my sisters took care of them and practiced all the measures, when they got very serious we called 132 to ask for an ambulance because we thought they were going to die, but thank God it didn’t happen,» he says.
And it is that in the first nine months of the pandemic, many families took their loved ones to the El Salvador Hospital where they died and were not seen again because they did not allow visits, and from the health center they were transferred under protocol to the cemeteries.
This led to multiple complaints from families, because, they say, they were not informed about the deaths of people or there were even cases where the wrong bodies were delivered, according to widespread complaints.
Out-of-hospital deaths or deaths due to misdiagnosis could increase the underreporting of deaths from covid-19.
«In the various waves there is an issue of underreporting of associated mortality where El Salvador appears as one of the countries that has had the most underreporting in terms of deaths and number of infections,» said epidemiologist Jorge Panameño.
In relation to the contribution of the specialist, the Central American Institute for Fiscal Studies (ICEFI), in its Bulletin 1 Monitoring of vaccination against COVID-19 in El Salvador, published in February of this year, indicates that according to Health evaluations of the University of Washington, United States, as well as by the Imperial College of London (ICL), in fact from the first case detected until December 31, 2021, in the country there have been 1.86 million cases, that is, 2,858 each day, which would imply an underreporting of around 1.74 million infections and deaths.
Likewise, the ICL estimates 2.18 million in the same period, that is, 3,342 for each day, which would indicate that the underreporting would be 2.06 million cases.
According to the epidemiologist Alfonso Rosales, of the American Public Health Association, this underreporting may be due to the fact that people who die as “suspected” cases of covid-19 are not officially registered as deaths from the virus, as he stated on YSUCA radio, in December 2021.
The deaths that did not count
In addition, The Economist has developed a machine learning model to calculate excess mortality in each country in the world and for each day of the pandemic.
In the case of El Salvador, by the end of 2021, the excess deaths were 19,006; that is, 400 percent more than the official data; this means 15,000 more deaths than the official ones. In fact, according to The Economist, El Salvador has one of the highest levels of excess deaths directly or indirectly associated with covid-19 in Central America.
In this regard, Panamanian, supported by the data provided by the WHO, assured that the underreporting of El Salvador is greater than 22,000 cases, one of the highest in Latin America.
“In the first three waves there is an underreporting of approximately 22,000 deaths with a diagnosis such as atypical pneumonia, suspected covid, and that really has no justification. Those deaths were associated with the pandemic. 22 thousand, a very high figure compared to the four thousand that the state recognizes. We are listed as one of the countries with the highest underreporting, and the latter is recognized by the World Health Organization,” he declared.
In this context, the publication dated June 13, 2020 made by the digital newspaper elfaro.net, indicates that the Ministry of Health did not respond to that medium a request regarding the total number of deceased buried with the Covid protocol in the country since the emergency started.
In addition, it highlights that in previous statements, the Minister of Health, Francisco Alabí, stated that «there is the possibility that a result is not there (when a patient dies) and cannot be defined as if this cause of death was due to covid. However, as it is a high suspicion, it is handled under covid protocol,» the official explained.
The Minister of Health, Francisco Alabí, accepted in an interview that El Salvador, like all countries, manages an underreporting of cases and deaths from Covid. Photo / Twitter, Francisco Alabi.
Who tells the truth?
These statements made it possible to not know for sure the real number of Covid cases registered in the country as well as the exact number of deaths.
“We have commented on how there is underreporting and that underreporting is applied both to confirmed cases and to patients who in some way developed lethality. Today the data on the official page is the lethality data that has been due to Covid with confirmed proof. But we also know that within the territory there are patients who have somehow developed symptoms that could be a case of Covid. But that there is no confirmatory test, ”said the health minister in an interview on June 30, 2020, on the local news program Tel eprensa.
He also assured that an analysis was being carried out to update the figures because there was an underreporting.
“An analysis is already being made of that sub-registry, there is a committee in which a comparison is being made between the previous year and this year in order to have data and be able to implement file analysis and in this way be able to make that discernment of whether whether or not it is about covid cases, but there is definitely an underreporting not only in the country but also internationally,” he added.
However, the latest data reflected on the official page does not indicate levels of underreporting and there is no official information from said committee on the search for possible cases of underreporting at the national level.
According to Panameño, one of the causes of the underreporting and total management of the health emergency is that the decisions were made from a partisan political perspective and the opinion of specialists or members of the medical union was not allowed.
“The management in general has been with a propaganda political background that exceeds all health criteria. The scientific, academic aspect to deal with the pandemic was ignored and replaced by political criteria,» he said.
Unemployment and economy
In the Las Mesas community, although it is true that the majority of families work in agriculture, there is a limited number of people who must leave the area and move to neighboring municipalities to work in various jobs, such as construction assistant, warehouse , auto mechanics or others.
Many were suspended during the mandatory quarantine period and rehired months later, but others became unemployed and to this day still do not have a formal job.
During the state of emergency, many businesses and industry sectors closed because the economy came to a standstill. In some cases, companies paid their employees for the first two months, but then were forced to suspend, terminate or lay off staff.
“Thank God, what was employment was not lost much, because those who go to work in other places are about ten people; the road is lonely and you walk two hours and this time ago it was dangerous. But most work here in agriculture,” said Angelica.
According to the study «COVID-19, youth, employment and measures for post-crisis recovery», presented by the Salvadoran Foundation for Economic and Social Development (FUSADES) at the end of 2020, official data from the Salvadoran Insurance Institute Social (ISSS), reflected a decrease in the number of active workers that began in March, the same month in which the limits on free movement were decreed.
Thus, from February to June, a total of 73,538 people with formal jobs had stopped working.
The lost jobs
According to data from Or musa, in the case of women, the greatest job losses are found in manufacturing activities (with a loss of 10, 258); followed by the activity of commerce, restaurants and hotels, transportation and storage (with a loss of 9,742) and professional activities, technical scientific and support administration services (with a loss of 4,918).
While in men, the greatest losses are in construction activities (with a loss of 13,269); It is followed by the activity of commerce, restaurants and hotels, transportation and storage (with a loss of 11,441), professional activities, technical scientific and administration and support services (with a loss of 7,219) and construction (with a loss of 7,008).
A survey developed by the organization indicates that in February 2020, 76.1% of the women and 74.9% of the men interviewed carried out some economic activity to generate income, while during the quarantine period, the percentages were reduced to 34.4 % and 32.0% respectively.
Current panorama of unemployment in El Salvador
According to the Minister of Labor, Rolando Castro, a year after the economic pause, the jobs lost during the pandemic had already been recovered, as he stated through the social network Twitter, on August 15, 2021.
«Not only have we recovered the jobs lost in the Pandemic, there is also already a surplus, it being clear that there is still a long way to go to eradicate unemployment in El Salvador, we are going in the right direction of history and we will bring opportunities to those who never had them,» the minister published.
The data as of April 2022, collected in the Labor Market Information System of El Salvador (Simel) indicate that the country registers 900,000 contributions since 2021, and that as of April 2022, more than 60,000 formal jobs have been generated with respect to the same month of 2021, which allows this month to have a total of 927,371 contributors on the payroll.
As a look from the outside, according to a World Bank (WB) report, published last April in Diario El Salvador, the pandemic had a significant negative impact on people’s lives and family incomes.
And it affirms that, although the country quickly adopted strong containment measures against the outbreak and the Government implemented a solid fiscal response to limit the impact of the pandemic on households and companies, the pandemic dealt a severe blow to growth and the Domestic Product. Gross (GDP), as this fell by 8 percent in 2020.
In addition, it indicates that poverty increased by 4.6 percentage points between 2019 and 2020. “However, estimates indicate that poverty would have increased by up to 7.6 percentage points without the mitigation measures implemented by the Government. Inequality is expected to have increased from 0.38 to 0.39,” the report says.
While in 2021, the World Bank reports that economic growth recovered to 10.7%, supported by consumption driven by remittances and exports. El Salvador’s economy is expected to grow 2.9% in 2022 and 1.9% in 2023.
Thousands of deaths, aggravation of other diseases, psychological and physical damage, thousands of lost jobs, school dropouts, and permanent damage to economic and social development, left the covid-19 pandemic in its first two years in El Salvador.