Interview with Dr. Mirna Gavidia (MG), Medical Technician of the

Interview with Dr. Mirna Gavidia (MG), Medical Technician of the

Interview with Dr. Mirna Gavidia (MG), Medical Technician of the National Vector Program
and Ing. Eduardo Romero Chévez (ER), Coordinator of the National Vector Program 8th of
December, 2015
... = pause in the speech
__= can’t hear what is being said
[ ] = when something is understood but not being said
( ) = If I am guessing a bit about what is being said from the context fx.
directive/guideline/norm = la Norma Técnica 
Before the start of the recording, we introduced ourselves and our project, and we asked if it was
OK for us to record the interview.
PR: As I mentioned, our interest is Chagas initiatives, and we are very interested in investigating the
benefits that can be obtained through vertical programs that are aimed at specific diseases, but the
diseases that can be obtained with respect to the health system in general. And firstly, we have some
questions about the integration, management, and administration of the program. We have read the
documents that you have on the website [of the MoH]...the Technical Norms (/Technical
Directives/Guidelines) and there is also a document on the historical developments of Chagas in the
country.
Well, we have read that JICA principally provided support en the chemical control, in the
entomological investigation and surveillance, and in the strategy of information, education, and
education, and also in the community participation. And what we would like to know is, how these
areas have been transferred to the national program? That is to say, who has taken over the
responsibilities which JICA had before?
ER: Hmm, point by point...Well, my name is Eduardo Romero, the Coordinator of the Program, and
Dr. Mirna Gavidia is also...she knows the Chagas program very well...We have participated a lot,
well, we are veterans of war in this. We have been working with Chagas since the year 2000...Us
here as a team. With relation to the integrality that you mentioned...the benefits that the managing
[of the program] left...the vertical of the program...there are some benefits of being vertical: there is
only one command, which follow the objectives of the country which are...which also comply with
the objectives of the Intiative of the Centralamerican countries, IPCA(M), which are: the
elimination of the Rhodnius Prolixus, the reduction of the infestation by the Triatoma Dimidiata,
also the elimination of the transmission through [blood] donors – that is the screening.
So all this steers us to have a verticality in order to do the activities of control at the community
level...This benefits us because...there is only one chain of command, like I told you, there is a
single objective which is...the objectives of IPCA(M), the Initiative of the Centralamerican
countries and Mexico. This gives us some benefits...the integration of the program, which you
mentioned...we, the program, do not only consider it an operative discipline but rather there are
various disciplines: the discipline of vector control, the discipline of sanitation inspectors, and the
discipline of health promotors which has the largest quantity of persons. We have more than 5.000
persons working in Chagas...the program is integrated in the profile of the technicians from the
different disciplines. We have a monthly information system...it is in line...which permits us to
continuously evaluate...it permits us to continuously verify what type of activities that are being
done at the community level... This has benefitted us...we have left the era of sending by fax or
reports by telephone, instead, whereever we are, we can generate a report...we have three
information systems which are the system of service production that is on a monthly basis; we have
the VIGEP – the epidemiological surveillance which is weekly...we verify the [state of the] disease
and the control activities and also the participation of other institutions in the surveillance and
control. This has permitted us to have an opportune register of more than 200.000 housing
inspections each year. This guarantees us that we can view the entomological rates/figures, the
entomological surveillance. It also permits us to evaluate the work of each of these disciplines, to
see the dispersion of the vector at a national level...we made a presentation [about this –
powerpoint]...it also...we make...we guarantee an integral approach...the integral management of
Chagas vectors, which is the epidemiological surveillance, the entomological surveillance, the
interinstitutional participation, transdisciplinarity, and also the part of community participation and
[vector] control.
This has permitted the integration of the program at the community level, which is the
entomological community surveillance which...since the year 2003, the beginning of the program...
in a more structured manner...in 2003 JICA began to work in three departments of the western part
of the country, which you have probably read, being Santa Ana, Sonsonate, and Ahuachapán which
is the continuation of JICA’s collaboration in Guatemala...which is the northern part of their
country, for us the west, which also enabled us to work in those three departments with JICA’s
support. As we are a small country, we standardized this benefit for the three departments for the 14
departments which is why...JICA was not...yes...physically, economically, and technically in 3
departments but in reality they were in 14 departments. Officially it was 3.
We worked very hard in the attack phase...the diagnostic which was made beginning in 1997 when
IPCA(M) began...in 2000 the blood banks were given directives so that since the year 2000 they
screen a 100% of the donors. Here, safe blood is given. In 2003 the attack phase began to function
with JICA...a technical phase. Japanese entomologists supported us. We worked very hard. A lot of
work was put into the strengthening of human resources with qualified medical
entomologists...entomologists were given certificates, 32 entomologists here in this country...they
were qualified and they were given a diploma by the national university or by private universities
which gave them this certificate. This guaranteed...there was a staging/scaffold, a strong integration
from the beginning of the entomology, being the diagnosis, the diagnostic part. Japanese doctors
helped us, Brazilians who came to the country to help us with the technical standard.
We had the first technical standard in 2007...[before] we were working in a technical manner but
not in a standardized manner...one department was working in one way, another one in another
way...in such a way that there was a hotchpotch...Then in 2007 we have a binding technical
standard with all the disciplines...connected to the other manners of control and approach. For
example, diagnosis, treatment, clinics, entomology, control, community participation...so this, in
2007, with JICA’s support...this strengthened us at the national level. The program was evaluated
with JICA in a...it is still being done....the program was evaluated with them, not only the 3
departments where they were physically but instead all the 14 departments of the country were
evaluated. This is the way that a standardization of the technical standard is done, just as we also do
a standardization in a practical and operative manner.
The technical standard is circulated to a 100% of the 7.000 technicians who are doing the operative
approach. It was standardized at the levels of epidemiology, epidemiologists, at the field level. It
was circulated among the laboratory technicians, a 100% became qualified. At the national level,
we have 189 laboratories. 189, including the national laboratory of referral. The national laboratory
of referral is a difference...we are the only country in America which detects acute cases but that is
because our norm, our human resources are technically able to carry out this approach...We saw
it...we did a conference on Chagas where Guatemala asked for our advising to do a type of audit in
Jutiapa which is the border area between El Salvador and Guatemala. We have Chagas here [El
Salvador side of the border], there in Jutiapa they have vectors but they do not have acute Chagas.
PR: They don’t detect it?
ER: They don’t detect it. It is a problem of norm...a problem of definition of cases
MG: And of diagnosis.
ER: And of diagnosis. They did not know Strout’s concentration method. That is, they made
examinations of chronic [patients], not acute. And with Strout’s concentration method, yes, you can
detect acute [cases]. So, a representative of our national laboratory of referral went to train the
Guatemalan laboratory technicians to detect the cases. So for us, it was a great satisfaction to be
generating this type of knowledge at the Centralamerican level...
With regards to the...as we were making the integration of the program with the other discplines, the
theme of Chagas is integrated into the profiles of the different technicians at the national level.
There are 360 vector control technicians. With 360 we cannot cover the whole country. It was
necessary to connect another discipline to our objectives, also achieving with this putting it
[information, activities?] in...I repeat...in the profile, in the...we call them daily data entries. In the
daily entry are...the activities that a technician carry out during a day. And Chagas is also in this
data entry. Later, we can look at how this system works so that you guys can see that also...it is not
just in paper but it is also functional.
Well, ”how is the administration of the program?”, you mentioned as one of your questions. The
administration of the program...the Ministry of Health is divided in 5 regions and 17 SIBASIs.
Managerially, we have a technical manager...like ourselves in each SIBASI. There are 17 vector
control technicians [SIBASI] and 5 regional vector control technicians. When we send out an order,
send out a guideline or directive, they are the operatives who...are in charge of operationalizing our
directive...that it, the entomological surveillance is pending [being carried out], that the treatment of
patients is being done, that the control of hot spots [of infestation] is being done, especially when an
acute case of Chagas appears.
This guarantees that the activities are being executed at the community level where...it gives us
more reliability about what is being done in the field. We [ourselves] do not necessarily have to go
everywhere nationally. We go where...the special cases [are]. In this way it is like we administrate
the program, we manage the program we... that structure that the ministry has. At communnity
level, there are more than 700 teams, the ECOS. That is, at the community level we...we have [ER
draws something at this point as an illustration for us]. We have the central level, there are 5
regions, and in those there are 17 SIBASIs. And from those [SIBASIs] 720 ECOS go out [to the
communities]. Community teams. So, they are the ones who do the inspections in the communities.
PR: And how often are they done?
ER: On a daily basis
[His phone rings, and he explains that he is in a meeting]
Well...so it is like this: they, the community teams are those who put the information into the
information system. The SUIS1. It is called SUIS – the sole/single/unique information system in
health. They are the ones who put the information here [in the system]. And we have a two-way
communication. So here [he draws and illustrates meanwhile] is where the entomological
surveillance is being carried out, and it is the passive entomological surveillance and the active
community surveillance.
PR: And do the ECOS teams collaborate with voluntaries from the communities, or how does it
function?
ER: Well, in their profile they have to have...they have assigned areas and within these areas it is
their obligation to make teams of...health teams they are called...so that they [community members]
involve themselves in the operative work...not only Chagas but in everything that is related to
health...and within this is Chagas disease.
PR: And when did it start, the use of this structure? Was it something that began with the Chagas
program, or was it something that was already existing [before the Chagas program]?
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Sistema Único de Información en Salud
ER: It is part of the health reform, it is part of the government. So we...it is part of the politics of the
government to bring the health [sector, services] closer to the communities. So we as a program...it
is also our obligation to integrate the Chagas program into these teams. To respond at a community
level.
PR: And when was this reform done?
MG: It is in process.
ER: Yes, it is still in process. It began in 2009, 2010.
PR: OK. So the Chagas program began, and when it was in function, something else happened
and...
ER: From 2003 to 2009 [things] functioned differently. From 2009 to 2015 is the second phase.
With the health reform, we also have to adapt to this reform...to give response, as I mentioned, to
the communities...which is also part of the range of health offers that our teams bring to the
community level.
PR: And what was the reason for this reform. That is, who started it?
ER: Well, the idea is to bring the health [sector, services] closer to the communities, and this
facilitates this type of process. That is, I am not waiting for the community to come to me...that is, it
is a way of working preventively. So in this way I avoid that my hospitals are overcrowded with
people who come for a consultation that could relate to...to a flu, or other type of simple...that could
be detected in the field/country...then the hospitals are not overcrowded. And this is facilitated. And
it is also evaluated so that the cases that need to be referred, are referred to a higher level for the
respective attention. So this permits us to increase the community approach, it permits us to
increase...it also permits us to do a larger inspection of housing at the community level.
PR: And for this general reform, were the experiences with the Chagas program used for it?
ER: No, they already had their program. At the political level, the idea was to bring, as I mentioned,
the health closer to the communities. So as it [the reform] has an approach which is more focused at
the communities, it was, logically, adapted to our objectives, interests of being in the
communities...as the disease, even though the WHO calls it ”neglected”, for us it is not that
neglected because we already had an approach [to Chagas]. We are the only country in America to
have eliminated a vector. In 2010 we were declared free of the vector Rhodnius Prolixus. Here, we
only have the Triatoma Dimidiata, we have the...the Ryckmani and the Triatoma Nítida but they
[the latter two] are not good vectors. So, this is the system, the approach, the health system has also
permitted us to improve in this. We still have to improve the approach.
PR: But in your opinion, the way of doing it [the reform] was something that you already had in the
health system? That is, the way of getting closer to the communities...was it something that you
already knew that you were going to do [in El Salvador]? It was not something that was introduced
from the outside?
MG: It’s that the figure of health promoters was used before...it was to have a person who was in
the communities and played the same role as the community teams but it was only one promotor for
a large area. However, with this reform that the new government established, the community teams
have a larger coverage. So, now it is not only one rural promoter in a geographically large area but
rather there are teams...with which the work is divided, and a larger coverage of the population is
achieved. But before, the community work was done through the rural health promoters.
ER: Look, Chagas is a community matter. We were already doing it in a manner...with less
coverage. When the new reform was injected, the health reform, logically it brought an increase in
human resources. So that, logically, led to that we increased our approach of field activities. But we
had already, as the Dr. Mentioned, a quantity of human resources, health promoters who were doing
this type of work.
MG: On the other hand, it is also important to mention the promotion that has been done related to
the disease, and in this, yes...JICA had a lot to do with it because they facilitated our work with the
voluntaries who came to make promotional activities related to the disease in the communities. So
the people got to learn a lot about the disease...so that led to that when the people saw chinches in
their houses, they brought them to the health units [/centers] so that they could examine them, and
in this way we became aware of how the community was. So in two ways it led to...the necessity of
reporting, right? And that they also went to them [the communities] to carry out their activities. But
the promotion that was done in this whole period, when JICA was here, was very, very intense.
PR: So, in your opinion, the most important with JICA was...the consciousness-raising about the
theme and the way of reporting findings of chinches?
ER: Well, JICA had an advantage...even we had to learn a lot at the direction level. The fact that
we, at a global level, are an example of a successful program in Malaria...from 160.000-150.000
cases which we had before, today we have 8 [000]. Our experience whas in the question of spraying
for the control of the transmitting vector of Malaria. We did Chagas but in a very direct manner, and
we applied the same spraying technique as for Malaria. When the Japanese experts came, they told
us: ”No, it is different”. Then, we began to become aware of things that we did because they were
ingrained. The advantage with JICA was that they changed our approach, from only considering the
vector to consider the program in an integral way. And one of the things related to this was to
strengthen human resources with regards to knowledge. Secondly, to consider the inclusive part: ”I
am not a doctor but I consider the clinical part, I consider the treatment”. We consider the part of
education and promotion, and what the Dr. mentions is: this integral approach that was done...we
did not just strengthen the part of vector control but also...laboratories...a 100% of the laboratories
were strengthened at national level.
So this approach...we did not promote it [before]...for example, this here [he points to a flipover
poster]...we did not do promotional activities related to Chagas...there were some related to Dengue,
there were some related to other pathologies. Not like that for Chagas...flipovers or other
types...brochures...other educational materials. They [JICA] came and put money into this technique
of structuring the educational material...In television there was a lot of dissemination of the
activities that the ministry was doing. So, all this came to strengthen the integral approach. Not just
a single line [of work with Chagas], we rather followed different lines.
MG: And it was not just in the communities but at all the different levels of attention. That is, from
the direction level, here with us, to the ministerial level, the regions, the SIBASIs – the personnel in
the SIBASIs, and it also reached the communities...everything in different scales...we had some
academic support too...in the sense that we could say that we came to know more about the disease.
ER: Another thing which strengthened us...were the meetings of exchanging experiences...we did an
exchange of experiences.
PR: Between the different countries?
ER: At a national level...that those from the east came to the west to see the Chagas approach there.
At a Centralamerican level we went...I went with the Dr. [MG] to see how...to give our experiences.
Actually, we were considered the best program...El Salvador...of some hundred or 200 JICA
programs globally...the best, successful. So we made the joke with the ambassador that our sin is to
have worked well. So...they told us: ”You are able to do it yourselves”...which...the system...the
health system permits us to ”stay on the train”...this with Chagas because the principal
people...well, we have to stay attentive.
PR: I was also thinking...you mentioned the integration between the different disciplines. Is that
something that...or rather, that way of working – is it something which can also be used for other
health themes than the Chagas program?
ER: For us, Chagas was an example for the approach because...to speak of Chagas...for example
we...we consider Chagas from a legal point of view as well. We made a legislative decree in which
a national Chagas day was declared. So this works as a model for other pathologies...for example,
Dengue, for example Leishmaniases, Malaria...well, in Malaria we had already gained a lot of
terrain with that experience [the earlier Malaria program], and we also built on that experience with
the case of Chagas today...now, the Chagas strategy is richer, it is more...with a lot of experience in
all the fields of the approach. Which is put to practice for the other pathologies...and as we are the
same, the two of us...at the level...in other countries there can be a lot of people in the
approach...they came here from Guatamala and Honduras to see how we were managing [the
program], and they expected to see a building, they expected to see a whole lot of people, working
with Chagas – ”No”.
PR: But does this make it easier...that it is a smaller team...that you do not have to coordinate with
more entities
ER: Yes
MG: The problem is that we are the same two for all the vector-borne diseases, not just for Chagas.
So, this takes...it takes our time...sometimes things that...were not planned...for example, this with
Malaria [A meeting about Malaria which they had to attend after the interview]...we are [currently]
practically a 100% [occupied] with Malaria but there are things that we cannot neglect but in some
ways...we cannot achieve it. But maybe, what we have learned is the organizational part of the
process of attention related to Chagas disease. Because from the direction level to the local level,
we have a chain of command and of action according to what is going do be done, right? So, yes, it
helps a lot. Now the work is not being done in a disorganized manner but instead well planned.
PR: And you also mentioned that with data entries...that are used for...
MG: Analysis.
PR: Analysis, exactly. Is that a form of work which is also used for other themes now?
ER: Yes, we use them for Dengue, Malaria, Leishmaniases. Including today, with the funds that we
are going to receive from the Global Fund, we are going to strengthen the system to make it
more...even more effective because we are going forward. That is, in Centralamerica, we are maybe
the only country which has systematized all the operative information...epidemiologic and
entomologic. For example, if I am in Denmark, and it occurs to me to make a report about a vectorborne disease, I go to the system, and I do it. So, it facilitates the processes of analysis and
interpretation. So we...you made a question: ”how did the ministry take over JICA’s
responsibilities?”...in reality, it was not a direct responsibility of JICA...it was a responsibility for us
as a country...so it was easier because we have a...a work ethic...well, beginning here we like to do
what we do. In the field it is the same, the people who work in Chagas, they like to do what they do.
PR: So it was more like...that JICA did not have the responsibility but it was more like...advising
MG: Support
ER: Advising
MG: Advising and support.
ER: For example...to tell you...that we through JICA...by being an international entity they have it
easier at the political level too...which...he who is President of the republic [El Salvador] today, was
the Minister of Education in the previous government. With him, an agreement of cooperation was
signed with the Ministry of Education. So, that permitted us to make some political advocacy...to
position the theme of Chagas at the policial level. And that...also with JICA, hard work was made in
2014-2015 which was the systematization of the experiences of surveillance and control of
Chagas...there is a book of...all the good [best practices] are systematized, I don’t know if you
already saw it?
PR: Yes, with the 4 countries.
ER: Yes, yes. So that also permits us...in that [the Best Practice Manual] they only put the
most...let’s say...they are all relevant...but that was a bit more political, technical...the approach with
the minister of education who is now president of the republic [which is one of the best practices in
the manual – the agreement between ministries].
So, it also permitted us to take over the responsibilities of all the pillars related to Chagas. Like I
told you, epidemiologic surveillance – We have a single/sole/unique information system where the
whole national health system contributes [with information]: the Ministry of Health, social security,
the teachers, the people from the military sanitation batallion, the private sector contributes [with
information] to the system to detect the acute cases.
PR: And how are the acute cases deteced? Do the people come with symptoms, or is it through the
daily inspections?
ER: You know, there are times...there are times when it is by...over time it is by the experience that
our people in the field have. For example, they see Romaña’s sign. The people [Health workers]
know what it is. So they send the case forward to the health establishment. Then, they see the sign,
which is not very common, but there [probably he means the hospital] is where the case is detected.
The other situation is by demand. The patient comes, he/she feels ill, he/she has been bitten, he/she
feels a chagoma or a....so they come to the doctor, and with the temperature and with all the signs
and symptoms...Strout’s concentration method is done, and that is where the case is detected.
PR: But as Chagas often is asymptomatic...that is, are there problems with...
ER: Yes, it is definitely also a part of the challenges that the Ministry is going to have to strengthen
the medical resources, also for the early detection of the acute cases. Because we have an average of
1.000 to 1.100 chronic cases in the blood banks, we have a law for the blood banks, a directive
which governs the public blood banks as well as the private ones...so that is where we have...the
two case detection systems...one of which is, logically, already historic because the blood donor is
historic [I think he means that the transmission through blood banks does not happen anymore but
cases can obviously still be found in blood banks].
PR: And also...you mentioned the agreement between the ministries of health and education. In
your opinion, can the experiences from that agreement be used for other health themes as well...or
are they already being used?
MG: It is already used in a way because Dengue is also being talked about [in schools]...because the
agreement is meant to put the theme of Chagas into the curriculum of the students in the school
classes. And Chagas is talked about with the children. And Dengue is also talked about. They are
the two pathologies which practically...have been taken up at the level of the ministry of education.
And apart from the curriculum, a school for the parents is also being managed. Where the parents of
the schools are invited every so often to learn about different themes, right? And here, the parts of
Dengue and Chagas are incorporated according to the time of year.
PR: And the issue of... making the theme more well-known...for example the ECOS teams, do the
also collaborate with other organizations from civil society or religious organizations or something
like that?
[ER’s phone rings. He takes it and says that it will be a few minutes to the person on the phone]
MG: Yes, it is part of the activities at all levels. From the regions to SIBASI, all the way to the local
levels...we call all the community family health units the ”local levels”. They have the obligation to
coordinate with other entities of the areas where they are. And according to the level, the
complexity of the level...for example, SIBASI is at the departmental level...they make relations and
coordinate with the mayors, with institutions like ANDA2, [local] governments...depending on the
area. At the local level with the schools, with the health unit of most complexity. That is, there are
always coordinations with different levels.
PR: But does the program also collaborate with organizations or actors that do not pertain to the
health system?
MG: Yes. Well, yes. For example, the mayor’s office. It does not pertain to the health system, and it
is part of the activities that...to coordinate with them to carry out specific activities.
PR: Another thing: We have read the when the acute cases are detected, the doctors should indicate
the treatment with Nifurtimox or Benznidazole. And we would like to know if the medicine is
always available, or if there are sometimes problems with the availability of the medicine.
MG: Well, yes. The medicine always...exist. It is very rare that we are without medicine. Last year,
the __ there was a problem because...before, the technical standard did not say that chronic patients
had to be given medicine...it was written in the technical standard that the chronic patients should
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The National Administration of Aqueducts and Sewers (Administración Nacional de Acueductos y Alcantarillados).
not be given medicine [Nifurtimox, Benznidazole]...just the acute patients, and the chronic patients
were treated according the pathology that they had as a result of the disease. But there were held
some very interesting conferences where studies and investigation had been done, in which the
chronic patients, when they were given the medicines [Nifurtimox/Benznidazole] – their functions
improved notably; the detected level of the parasite diminished, and so they improved...for example,
the problems of the cardiac patients improved notably...so this generated, with a bit of __, in the
sense that the people started to feel: ”We have to give it [medicine] to the chronic patients because
they get better”. There was a moment when the chronic patients...some chronic patients began
treatment...and there was a bit of a medicine gap...but generally we always have for the acute
patients.
ER: All the medicine...we receive is of donative character from the OPS – PAHO. We have not had
a shortage but we had a bit of a scare, let’s say, because we changed the technical standard. Before,
only the ones under 15 years could be treated. Now, because of the studies that have been presented
and demonstrated to us...that while the chronic patients are not cured...there is an improvement as
to...
PR: The symptoms?
ER: Exactly...So this compelled us to put in the technical standard that a 100% of the chronic
patients should be treated, and with the respective clinic follow-up. Not just to give it to them like
any other medicine but rather, it is a strictly supervised treatment – one [point number one]. Two:
We have also done a study with JICA...JICA also left us this great...this great school of the
investigative part. We have had a lot of work published by them...which we have published
together. Which...we did a study of the congenital transmission which demonstrated that children
born of Chagasic mothers have a good possibility...logically, of direct transmission. And this also
compelled us to change the technical standard to screen a 100% of the pregnant mothers...that is, it
was not the norm [before]...but yes, now it is a part of the norm, in the new technical standard, the
screening of a 100% of the pregnant mothers.
PR: Perfect. We also have a few questions about the spraying of houses. Do you know how often
this spraying is carried out at the moment, more or less?
ER: It lasts 3 months. That is, that we...the spraying has 3 conditions in order to be executed. The
spraying, for example...the first one is...concrete risk, logically. For example, one is if an accute
case appears. And if the case turns out to be native of the place, and investigation is made around
the case [where it was found], and if the vector is found, a 100% of the area or the small town from
where the case came from. Sprayings are also done in those localities that have [infestation] rates
above 5% because the technical standard says...below 5% is low risk and above 5% is high risk.
That is another condition for...one: to program a locality for the respective spraying. That is also
being evaluated every 6 months, the presence of the vector...that is, every 6 months there is an
evaluation to verify if there is presence of the vector. If there is presence after the spraying, a
selective spraying is done, and this is not of the whole community but selective where there is risk.
For example, houses constructed with mud walls, that is, a type of material, or the ones constructed
with adobe which is a brick which is not cooked. So, that makes a perfect habitat for...the vector
which transmits Chagas.
PR: Are efforts also done to improve the conditions of the houses? That is, the walls, the roofs...
ER: We as ministry only do coordination. That is, we make recommendations and also
coordinations with respective communes or non-governmental organisms, the NGOs which are
devoted to this. Or with the municipal governments. That is...or we make recommendations within
our possibilities in the field...that they engage in filling, plastering the houses for this...
PR: And another thing...concerning the spraying...when the spraying was begun...or the Chagas
program. Was it easy to diffuse the spraying techniques, or were there problems related to this?
ER: The problem we had, was the quantity of equipment. We did not have equipment. The JICA
came and they contributed with a quantity of spraying equipment. For...the community level. The
problem, as I mentioned, in the beginning was that we were experts in the question of Malaria, in
the question of the spraying which has one technique. The distance of the nozzle to the wall, the
quantity of active ingredient per square metre. We wanted to do the same with Chagas, but there:
”No”. Because of the type of vector...a different technique. That is, to bring the nozzle closer to
where there are perforations, where there are cracks...we had to bring the nozzle closer. That is, we
changed the spraying technique according to the specifics of the disease. Chagas also permits us,
and has permitted us to have a larger...an average of 23.000 houses are sprayed each year. Which
permits the community participation in the spraying. The health resources [personnel] are not the
only ones doing the sprayings but instead the ECOS teams have organized the communities to carry
the equipment, the chemical input...they [community members] are trained and they are the ones
who carry out the spraying.
PR: Voluntaries?
ER: Voluntaries. That is, there is a socialization, a democratization, to put it that way, of the
operative activities, not just related to health. Now, it is not exclusively the Ministry of Health.
One, which favours us, is the spraying technique...not just a technique of __, of applying the
product but rather...with all the means of biosecurity, with the training and the entomological
evaluation...to see the impact of the...spraying in the community [I think this meant that there is a
democratization and socialization, not just of spraying techniques but also of the entomological
evaluation and the means of biosecurity which can be taken by community members]
MG: Also, the booklets were made...did you see them?
PR: There are two, right?
ER: There are two guidelines...
MG: That has...it is with the objective of standardizing the spraying methodology.
ER: We were the first to do this. Why? Because our directives of...the Regulation Department,
which governs us in making such regulatory documents, did not allow that type of documents [with
illustrations instead of a lot of text]. But we said, we pleaded that, well, if there are people who
cannot read...there are people with a slightly smaller capacity of interpretation.Then, it is better that
some pictures/drawings...those orientate the people who are getting involved in the operative work
more.
PR: And the voluntaries who carry out the spraying, how are they selected? That is, do they
volunteer themselves, or?
ER: There is a spectrum, a difference...there are different ones. There are some who volunteer, or
who have the experience in the agricultural fields...they do spraying...in the crops [not of Chagas
insecticides, I think. They have experience with other forms of spraying]. They say: ”I will do it”,
or they are also selected in...meetings that are held in the community where the problem and this
situation is brought up...so the ones who can do it are identified and they are selected.
MG: Some communities have a health committee, and those committees are those who take up the
promotion of the [activities related to] disease...for example, in Sonsonate where we went with the
ambassador from JICA...there was a man who was part of a committee, and he was so conscious of
the situation that he promoted for example...because he had changed...let’s say, the way of living in
his house to improve the health conditions. And he promoted this...so the communities also take it
up [the promotion]...through the community organization.
PR: Finally, we also have some questions about the benefits of the collaboration with JICA. In your
opinion, what have been the major benefits of the involvement of JICA in Chagas control?
ER: I think it would be unfair to number them...the benefits that they have given us. It does not have
a level of importance that...they all have a extraordinary high level of importance for us. Because
they have left a benefit, as I told you, in 5 or 6 pillars of approach for any vector-borne disease. For
example, epidemiological surveillance, entomological surveillance in its two phases: community
entomological surveillance [passive] and the active entomological surveillance, which is ours. The
passive is not ours [it is by the communities]. The other situation is the part of...the investigative
situations...the baggage, the experience as to the...to investigation, which they have left us with, has
been incredible...so not only...we began with Chagas, we are [also] working hard in the
investigation of Dengue, we are working hard in investigating the chemichals that we are using. So
that strengthened us. The other benefit that JICA left us with, is the matter of human resources that
is invaluable as to knowledge, attitudes, and the practice of our people... Because even with a lot of
knowledge of Chagas, it is not [necessarily] put into practice because ”I don’t like it”...there is this
motive...but in those cases they left us with a strong legacy in the matters of knowledge,
organization, and planification.
PR: And is it something that can be used for many issues?
ER: Or rather, this thing with Chagas has been a sketch for other pathologies...and as we are also
the ones you see here [the two of them, working with other vector-borne diseases], this
situation...facilitates us.
PR: Another thing. In the last few years, since 2011 when JICA ended its part, has the strategy of
Chagas control changed, or is it still the same?
ER: It has been strengthened...having more...more actors. That is, as I told you, the pillars that
address Chagas are going to be the same: epidemiological surveillance, I repeat, epidemiology,
entomology, control and the matter of diagnosis and treatment, epidemiological surveillance, and
the community participation are the common denominator for the other pathologies. It has been
strengthened...also as other pathologies have permitted us to open new fields of action in other
areas... so that we also, as responsables of the area, mix in Chagas in every moment or situation that
presents itself. For example, instead of having just one... we had a day trip with the troops a
weekend with chronic Chagas patients that...we were talking about the clinical issue and we ended
up talking about the vector; where our troops live, how they live. So there are situations which
permits us to get more...more work force at the different levels. That is....Chagas has been
fundamental for the other pathologies.
PR: And also...in your opinion, what are the major challenges currently in the prevention of
Chagas?
ER: Well, the major challenges that we have...there are various...the major challenge is to involve
the training schools of the human resources in order to...that they dedicate more time to the theme
of Chagas. [There are] Challenges in different areas, for example, we have the challenge of
epidemiological surveillance....the challenge, which I mentioned, is to continue to strengthen the
unique/sole/single, information system in order to...because these systems are perfectible...the other
thing is: to continue to look for more than what we already have. Therefore, we mentioned that
another challenge is the permanent review of the information system...the other challenge is in the
matter of surveillance and vector control...which is to potentiate the different disciplines more in the
activities of surveillance and vector control, to keep the entomological surveillance active through
the communities is another great challenge.
PR: And why is that a challenge? Is it necessary to do more workshops or...
ER: To amplify it more, to have more...nationally we have a good surveillance but we also need to
strengthen in this point.
PR: Another thing. We have read that the role of PAHO has been the technical advising. And how
have PAHO participated?
ER: When JICA were here, the PAHO was also...a technical entity...for us a point of
reference...which...because of the multiple works that we are doing in different pathologies...we
have a greater approximation to the technical approach...more technical support, more financial
support also...how amazing, the money, right?...well for example, they designate some funds to
training, funds to evaluate. That is, this facilitates our work...it strengthens us, as we see in an
opportune way that those are the activities or means that we have to correct or reorientate. So
PAHO is, logically, a point of reference and they support us...they get involved in our daily work in
vector control in Chagas and other pathologies like Dengue, Leishmaniases.
PR: Perfect. Well, finally we just wanted to know if there is something important which we have
not asked about, in your opinion, or something that you would like to add?
ER: I think that....talking about Chagas, as I told you, is something that...with very interesting
themes because...we remain in debt with some things that we have to continue to investigate...at the
hospital level, at the community level in order to tighten up more. Well, we have certain
publications pending with PAHO...we have worked with them in the theme of characterizing the
Chagas transmission in the western part of the country...
MG: And maybe the necessities that are felt in the country is the financial support as to promotion
because...in terms of the promotion we, maybe, feel the decrease...with JICA we had much support
for those posters, flipcharts, paper articles etc. So this has diminished because of the lack of
financial resources. So this, yes, it is needed from the collaborators that they support us with this
now. We talked about this with Ken Hashimoto that we...what we asked for was not the fist but
instead that they taught us to fish __..an opportunity. And really, this was, what was achieved with
JICA: they brought us a lot of knowledge in order to be able to advance. But we also need, as a
country, that financial support for the matter of promotion.
ER: What the Doctor mentions is also that it is important to emphasize...we are...we function
without funds...only with government funds. We are not...there is not a...cooperation organism...yes,
like the ones they might have in other countries...there are funds from...in South America a lot
support from the Fundación Española...in Guatemala...but here, no. Only with government funds.
PR: And in Honduras there are funds from Canada
ER: Canada
[everyone speaks at once for a bit]
ER: Just to give you an idea. Last week, or maybe two weeks ago, I went to a meeting in Costa
Rica. We were to go ourselves but we could not go, so it was another colleague...we did the
presentation...this is us [he is pointing at a map]...El Salvador. We have the border with Guatemala
here, it is where we have the western part of the country, and here we have Jutiapa, Concepción, in
Guatemala...here we have...the largest border with Honduras...where we have done entomological
studies to search for the Rhodnius Prolixus nationally, and we did not find it. So we are divided in
14 departments, 262 municipalities...
MG: 5 regions.
ER: Yes, as we are...this is...as this country is geographically distributed in 14 departments, 262
municipalities, we have structured the health system in the same way...we have 5 regions, the
western region, the central region which is La Libertad and Chalatenango, the metropolitan region
which is where we are in San Salvador, the paracentral region, and the eastern region which covers
4 departments. JICA was in those three [he is pointing], they were in that one, they were in
Usulután, San Miguel, and Morazán...7 departments...we have 5 regions, 17 SIBASIs, as I
mentioned...
Here are the community health teams that are...as you see...all of this quantity of dots [on a map] is
where we do the entomological surveillance...it is where we do the community entomological
surveillance.
PR: And there are 480 of these teams [looking at his paper]?
ER: Yes...we have 700...in total 700. Here it is in detail...we have maternal waiting homes...so that
those mothers who are hospitalized in the health establishments and who have risk criteria...in the
question of abortion...that is when the occasion is also used to make a Chagas diagnosis...We
have...184 it says here...but we have 189 laboratories...all of these laboratories are qualified to do
Strout’s concentration method for the diagnosis of Chagas.
PR: And when were these laboratories started? Before JICA?
ER: These are from...before JICA. But the number has increased year by year. So we have the
National Laboratory of Referral which...what does the National Laboratory of Referral serve for?
The technical standard says that all these laboratories carry out Strout’s concentration method. They
have to send a 100% of the positive cases to quality control and 10% of the negative cases to the
National Laboratory of Referral for verification of the certainty of the diagnosis. So that guarantees
the quality of the laboratories nationally. They are all able to do the Chagas diagnosis. A 100%.
Historically, we have...even though we have more years to present [he is showing a chart with
different years]...we only have the age groups that have been affected...2013, 2014 the age groups
that we have which are affected with acute Chagas [he is showing this on a paper]...where we have
the transmission...the transmission of acute Chagas is centred in the west of the country...remember,
I told you that here we have Guatemala, and they do not detect cases...they do not have cases...we,
yes we do. It is...it seems pretty risible/laughable...there is the border. Logically, there is not a wall
or something like that. Here at 50 metres [from the border] – Chagas chases...and from here to there
– nothing. And the vector is there. But it is because of....
PR: The capacity to detect it?
ER: Yes
ER: So we have the year 2011. Look how the transmission is [again, he is showing something]...in
the west...the transmission in 2012 is the same...2013 and 2014 we also have transmission where
there are dots...in other parts of the country...where we have...untril week 44 in 2015...we do not
have the concetrated transmission in the west of the country...these here are acute Chagas...here we
have the seropositivity in....infectious agents...in blood banks in El Salvador from 1997 to 2015.
This work was published in the Instituto Fiocruz...here in 2015 we have 1,6. Meaning that it has
been achieved to sustain, maintain the seroprevalence...meaning that of a 100 cases, of 100 donors,
2 are turning out to be Chagas positive. And we have, you know, Chagas a lot higher than HIV,
Hepatitis C, Hepatitis B. This is blood banks...and we have the community entomological
surveillance....it is....it means that the population brings chinches to the health workers. And this
generates an action...how is the distribution of the vector? We have it in 262 municipalities...here
[in the presentation] we see the type of vector that we have...the yellow is where the Ryckmani is,
which was discovered in 2010...and here with the red dot, Sonsonate, the Nítida...but the Triatoma
Dimidiata is in the 262...here, we have the infected houses from 1997 until 2015...I find this in the
[information] system]...sprayings of housings [he is showing something]...how many houses have
been sprayed in 2015...municipalities where sprayings have been carried out...what you asked me
about...these are the challenges, the challenges will be in different aspects: epidemiological
surveillance, in the surveillance and control of the vector – what are going to be my challenges? The
diagnostic capacity – what [challenges] will it be? And access to treatment – what are going to be
my challeges? In health promotion...and in human resources...what are the next steps that we have
to take? To diffuse the technical standard that we already finished...it is already done, we only need
to diffuse it...Chagas conference... __ __ in the framework of neglected disease...that is...politically,
the reform had 8 axes [akser]...the health reform had 8 axes. But beginning in this year, we
integrated one which is the axis of environmental health. So it is also [a challenge] to integrate the
theme of Chagas into the framework of the ninth axis of the health reform.
[The next part is small talk but afterwards a more useful bits are there]
PR: Perfect. Can you give us that presentation? I have a USB here...
PR: By the way, a thing I forgot to mention is that our investigation is for our master’s thesis, so it
is not something which we intend to publish. But in the future, if we have the opportunity to publish
it, we are going to ask for your consent again. And another thing...if you wish, you can remain
anonymous in the investigation...that is, our supervisor recommended that all the persons whom we
interview should be anonymous in the investigation.
ER: Why did you chose Chagas?
PR: Actually, a bit by coincidence because we began to investigate the theme of...medicines for
neglected diseases...and we found Chagas disease, and I was in Bolivia a year ago, and I also heard
about the disease there...so we began to investigate, and we found out that there is a program of
Doctors Without Borders [MSF] in Bolivia, and we also found the programs of Centralamerica.
And therefore, there were a lot of things to investigate, and we have also interviewed a person from
the MSF. And we began to read a lot, and after some time...it is very interesting to us, right? When
you spend time on something, it becomes more interesting, and now we have already worked with
this theme for 5 months, so now it interests us a lot to know more about all the efforts in the
different countries.
ER: That’s good. I was also in Bolivia, seeing this issue.
MG: And when you finish the thesis, you will send us a copy.
PR: Yes of course, actually we have talked with Mr. Hashimoto too
ER: Ken Hashimoto
PR: Yes. Because we looked for articles about Chagas, and there is this thing called the Publich
Library of Science [PLOS] in the internet. And we looked for articles there, and found some
persons who have written about the theme...and we found Mr. Hashimoto, and he gave us the
contact information and everything, and we are also going to talk to him in January, and there is
also another Japanese expert who has worked in Nicaragua...
ER: Is it this guy...Jiro?
PR: No, he is called Kota Yoshioka.
ER: Ahh, Kota...he married a Nicaraguan
PR: Ahh..we didn’t know that...actually, he told us that he is going to return to Nicaragua in
January...
[From here it is interesting again]
ER: They...the issue continues...but it is because...as they do not visualize the mission that the
country should be prepared to...let them manage the program themselves...on the other hand, here,
they suddenly said ”no”. Our minister asked them to stay more time involved in the work with
Chagas.
PR: But no?
ER: ”You are already able to do it yourselves”, they said.
PR: Ahh ok. It seems to us that El Salvador is the country with most capacity to detect the
cases...to...
ER: In human resources too. That is...when you have the opportunity to see other countries, there is
not institutional human resources, approach for the disease as here. Here, we have 7.000 [persons].
They look at other pathologies too, but we have 7.000 men and women who are working in this.
PR: And this has been the most important part...for you to have this capacity to do it yourselves,
right?
ER: yes yes. So also our human resources who are not operative...even though they do not have a...a
highly academic knowledge, they have the capacity of community management...they can
administrate with municipal governemtents...to contract human resources....that is – how does the
municipal goverments support? To contract human resources, to get involved in the educational and
promotional matters...in whichever situation, but they work. That has permitted us a lot to be selfsustaining from 2010...March, 2010 the mission withdrew, and then no more.
PR: But that is a good thing, right?
ER: Yes!
PR: That they could withdraw
[Again everyone speaks at once for a but]
ER: Yes, because they let us go, and we walked for ourselves. It is like a child...you let it go to see
if it falls...so we have stayed on our feet...considering how to improve this. And always to improve,
always improve...what we already have. Because that is our challenge. And there was this Japanese
expert...I think...that it was mentioned that...Emi Sasagawa was with us...she said in Japan...or in
Centralamerica she said ”El Salvador are the best”, she said, ”I want to go somewhere else”...
PR: To a place where there is more to improve?
ER: That is...in Honduras, Nicaragua...the same...however, we go....she was the last one to come
with the program on JICA’s part. Basically that....well, are there other things that would interest
you? We are at your disposition.
[Again there is a bit of smalltalk, and again there is a bit more useful afterwards]
PR: Perfect. Well, more than anything we would like to thank you for your time. It has been
extraordinarily informative y we would also like to know if it coul be possible to visit a health
center, or something like that....?
ER: How? When are you going home?
PR: We are going to stay until the 21st of december, and on the 16th we have an appointment with
JICA, and well...
ER: The mail I sent you, there you have the mail for PAHO...Victor...
PR: Mejía...but it seems that it does not work because I received a mail of...
ER: Thrown away...
PR: And we would also like to talk to some persons from the university if possible, or with Mr.
Cedillos..
ER: Well, Dr. Cedillos, yes...I am going to give you the...with Victor Mejía.
[He writes a note to us]
ER: We have taken the time to talk to you because you deserve it.
PR: Thanks, thanks....and it is another perspective with....talking to persons instead of just reading.
ER: We....I do not read a lot...we work more.
[Again useful]:
ER: Well, recently...a month ago, 1.200 vials of Nifurtimox came, donated by...the funny thing is
this...the laughable about Chagas, about the medicine is that the only country where they make
medicines is El Salvador...Bayer
PR: The Nifurtimox?
ER: Yes, they make it here...from here Bayer donates it to Switzerland to WHO. And from there it
comes to Uruguay, Brazil, Panama, and back to El Salvador [laughs]
[his phone rings and he talks to Victor Mejía from PAHO; we get some contact information to
Mejía]
We also make the appointment to talk to José Luis, whom Romero calls on the phone
Efter the interview:
ER says that PAHO buys a lowering of cases..they drive us to the hotel on the way to their meeting.
Entrevista con Dra. Mirna Gavidia (MG) y Ing. Eduardo Romero Chévez (ER) 8.12.2015
(Inden da har vi introduceret os selv og spurgt om det er ok at vi optager osv.)
PR: Como les mencioné, nos interesan mucho las iniciativas de Chagas, y nos interesa mucho
investigar los beneficios que se pueden obtener a través de programas verticales, dirigidos a
enfermedades específicas. Pero los beneficios que se pueden obtener en cuanto al sistema de salud
en general. Y primero, tenemos unas preguntas sobre la integración, la gestión y la administración
del programa.
Hemos leído los documentos que tienen en la página...la norma técnica y también hay un
documento sobre la evaluación histórica de Chagas aquí en el país. Bueno, hemos leído que la JICA
principalmente ha apoyado en el control químico, la encuesta y vigilancia entomológica y en la
estrategia de información, communicación y educación, y también en la participación comunitaria.
Y lo que quisiéramos saber es cómo esas áreas han sido transferidas al programa nacional? O sea,
quién ha asumido las responsabilidades que la JICA tenía antes?
(1:45)
ER: Hmm, por partes: Bueno, mi nombre es Eduardo Romero, el coordinador del programa, y la
Dra. Mirna Gavidia también es...sabe mucho el programa de Chagas...hemos participado mucho,
este, somos veteranos de guerra en esto. Estamos desde el 2000 trabajando en Chagas...nosotros
aquí como equipo...En cuanto a la integralidad que tu mencionabas...los beneficios que dejó la
gestión...lo vertical del programa...hay unos beneficios que al ser vertical, sólo hay un mando. El
cual obedece los objetivos del país que es la...que se rige por los objetivos también de la Iniciativa
de los Países Centroamericanos, la IPCA, que es la eliminación del Rhodnius Prolixus, la reducción
de la infestación del Triatoma Dimidiata, también la eliminación de la transmisión a través de
donantes – o sea el tamizaje. Entonces todo eso, nos rige a nosotros también hacer una verticalidad
para hacer las acciones de control a nivel comunitario.
(3:15)...Eso nos beneficia porque sólo hay un...es una ley de mando, como te digo, un solo objetivo
que es...los objetivos de la IPCA, Iniciativa de los países Centroamericanos y México. Eso da unos
beneficios...la integración del programa que tú mencionabas – nosotros, el programa no solamente
lo ve una disciplina de operativa, sino que hay varias discplinas: la disciplina de control de vectores,
la disciplina de inspectores de saneamiento y la disciplina de los promotores de salud que es la
cantidad de personas más grande. Tenemos más de 5 mil personas trabajando en Chagas – está
integrado el programa en el perfíl de los técnicos de las diferentes disciplinas. Tenemos un sistema
de información mensual...está en línea...lo cual nos permite ir evaluando...nos permite estar
verificando qué tipo de acciones están haciendo a nivel comunitario. Esto nos ha beneficiado...ya
salimos de la era de estar mandando por fax o informes por teléfono, sino donde quiera que
estemos, podemos generar nosotros un informe...tenemos tres sistemas de información que es el
sistema de producción de servicio que es de forma mensual, tenemos el VIGEP – la vigilancia
epidemiológica que es semanal que verificamos...la enfermedad y las acciones de control y también
la participación de otras instituciones en lo que es la vigilancia y control. Lo cual nos ha permitido
tener un registro oportuno de más de 200.000 inspecciones de viviendas cada año. Lo cual nos
garantiza ver los índices entomológicos, la vigilancia entomológica. También nos permite ir
evaluando el trabajo de cada una de esas disciplinas, ver la dispersión del vector a nivel nacional...y
ya hemos __ (lavet en) una presentación. Lo cual nos también...le hacemos...garantizamos un
abordaje integral...el manejo integral de vectores de Chagas que es vigilancia epidemiológica,
vigilancia entomológica, la participación interinstitucional, transdisciplinalidad y también la parte
del control y la participación comunitaria.
(6:02)...eso nos ha permitido también la integración del programa a nivel comunitario que es la
vigilancia entomológica comunitaria que a partir del 2003, que inicia el programa, ya de una forma
más estructurada...2003 ya inicia la a JICA trabajar en lo que es tres departamentos del occidente
del país, como ustedes ya lo han deber leído, está Santa Ana, Sonsonate y Ahuachapán que es la
continuidad de la colaboración de la JICA en Guatemala que es la parte norte de ellos, para nosotros
la parte del occidente, lo cual nos permite también hacer un abordaje en estos tres departamentos
con el apoyo de la JICA. Como somos un país pequeño, ese beneficio para tres departamentos lo
hacemos nosotros estandarizado a nivel de los otros 14 departamentos por lo cual...la JICA no
estaba...sí..físicamente, económicamente y técnicamente en 3 departamentos, pero en realidad
estaba en 14 departamentos. De una forma oficial eran 3.
(7:15)...trabajamos muy fuertemente lo que es la fase de ataque...el de diagnóstico que se hizo a
partir del 1997 cuando comienza la IPCA(M)...2000 se normatizan los bancos de sangre que a partir
del 2000 tamizan al 100 % de donantes. Aquí se le da sangre segura... 2003 ya comienza esto a
funcionar con la JICA ya de una fase de ataque. Una fase técnica. Nos apoyan entomólogos
japoneses. Trabajamos muy fuertemente. Se trabajo mucho en lo que es el fortalecimiento del
recurso humano con diplomados de entomología médica...se certificaron entomólogos, 32
entomólogos aca en el país...se certificaron, se les dio un diploma por parte de la universidad
nacional y universidades privadas que se les dio ese certificado. Eso vino a garantizar...hubo un
andamiaje, una fuerte integración desde el inicio de lo que es entomología, lo que es diagnóstico...la
parte de diagnóstico. Nos apoyaron médicos japoneses, brazileños que vinieron al país a apoyarnos
en la norma...tuvimos la primera norma en 2007...veníamos trabajando de una forma técnica pero
no de una forma estandarizada...un departamento trabajaba de una forma, otro de otro...de tal forma
que había una mescolanza de (control??). Ya en 2007 ya tenemos una norma vinculante con todas
las disciplinas...vinculante con las otras formas de control o formas de abordaje. Por ejemplo,
diagnóstico, tratamiento, clínica, entomología, control, participación comunitaria...entonces esto,
2007, ya con el apoyo de la JICA...eso nos fortaleció a nivel nacional. Se evaluaba el programa con
la JICA de una forma...todavía se hace...se evaluaba el programa con ellos, no solamente los 3
departamentos donde ellos estaba físicamente, sino que se evaluaba los 14 departamentos que tiene
el país. Es así que se hace una estandarización en la norma como también se hace una
estandarización de una forma ya práctica, operativa. Se socializa la norma al 100% de los 7.000
técnicos que andan haciendo un abordaje operativo. Se estandarizó a nivel de epidemiología,
epidemiológos, a nivel de campo. Se socializó con los laboratoristas, se capacitó al 100%. Tenemos
a nivel del país 189 laboratorios. 189 incluyendo el laboratorio nacional de referencia. El
laboratorio nacional de referencia es una diferencia que somos el único país de América que
detectamos casos agudos, pero es porque nuestra norma, nuestro recurso humano está tecnificado
para hacer ese tipo de abordaje. Lo vivimos (/vimos?)...hicimos un con congreso de Chagas donde
Guatemala nos pide asesoría para hacer un tipo de auditoría en la parte de Jutiapa (?) que es la parte
fronteriza El Salvador – Guatemala. Nosotros tenemos Chagas acá, ellos acá en Jutiapa (?) tienen
vectores, no tienen Chagas agudo.
PR: No lo detectan?
(11:30) ER: No lo detectan. Es problema de norma. Problema de definición de casos
MG: y de diagnóstico.
ER: y de diagnóstico. No conocían el concentrado de Strout. O sea se les hacían un examen de
crónicos, no agudos. Y el concentrado de Strout, sí se puede detectar agudos. Entonces nuestro
preferente del laboratorio nacional de referencia fue a capacitar los laboratoristas guatemaltecos
para detectar los casos. Entonces eso para nosotros fue de mucha satisfacción de estar generando
eso tipo de conocimiento a nivel centroaméricano.
(12:13)...Eso con respecto a la...como veníamos funcionando la integración del programa con las
otras disciplinas, se integra el tema de Chagas en los perfiles de los diferentes técnicos a nivel
nacional. Los técnicos de control de vectores son 360. Con 360 no podemos nosotros darle una
cobertura a todo el país. Era necesario vincular a nuestros objetivos otra disciplina, logrando con
ello también ponerles en el...como te repito..en el perfíl..en el...nosotros los llamamos acá
tabuladores diarios. En el tabulador diario es...la acción que hace un técnico en el día. Y dentro de
este tabulador está lo que es Chagas. Posteriormente vamos a ver como es que funciona el sistema
para que ustedes puedan ver que también existe...no es solamente en papel, sino que es funcional.
Bien, ”cómo es la administración del programa?”, mencionabas una de tus inquietudes. La
administración del programa, el Ministerio de Salud está dividido en 5 regiones y 17 SIBASIs.
Gerencialmente, tenemos un referente técnico...Igual que nosotros en cada SIBASI. Son 17 técnicos
de control de vectores y 5 técnicos regionales de control de vectores. Cuando nosotros emanamos
una orden, emanamos un lineamiento o un dispositivo, ellos son los operativos de...sólo encargado
de operativizar esa disposición nuestra. O sea que esté (en) pendiente la vigilancia entomológica,
pendiente los tratamientos de pacientes, pendiente de los controles de foco cuando aparece un caso
de Chagas agudo especialmente.
(14:32)...Eso nos garantiza que las acciones están ejecutando (/ejecutados?) a nivel comunitario que
de donde sí nos....nos da mayor fiabilidad de lo que se está haciendo en campo. No necesariamente
tenemos que ir nosotros a todo el nivel nacional. Vamos adonde...aquellos casos especiales. De esa
forma es como nosotros administramos el programa, gerenciamos el programa con esa estructura
que se tiene el ministerio. A nivel comunitario hay más de 700 equipos, los ECOS. O sea que
nosotros a nivel comunitario...nosotros tenemos como te digo [han tegner]. Tenemos el nivel
central, vienen 5 regiones de salud, y de acá salen 17 SIBASI. Y de acá salen más de 720 ECOS.
Equipos comunitarios. Entonces ellos son los que me hacen la inspección en las comunidades.
PR: Y con qué frecuencia se hacen...
ER: Diaria. Diariamente
[Tlf. Ringer] han tager den og forklarer at han er i møde.
(16:35)...Bien, entonces es así: ellos, los equipos comunitarios son los que tributan el sistema de
información. El SUIS. Se llama SUIS – Sistema Único de Información en Salud. Ellos son los que
__ (vigitan/digitan – placerer) información acá [en el sistema]. Y tenemos una comunicación
bidireccional. Entonces acá [mens han tegner og viser] es donde se hace la vigilancia entomológica,
comunitaria y es la vigilancia entomológica pasiva y la vigilancia entomológica activa.
PR: Y los equipos ECOS colaboran con voluntarios de las comunidades o cómo funciona?
(17: 28)
ER: Bien, ellos dentro de su perfíl tienen que tener...tienen áreas asignadas y dentro de estas áreas
tiene por obligación hacer equipos de...equipos de salud les llaman ellos...para que se involucren en
el trabajo operativo...no solamente Chagas, sino que todo lo que concierne a salud..y dentro de esto
está lo que es la enfermedad de Chagas
PR: Y cuándo se empezó a utilizar esa estructura? Era algo que inició con el programa de Chagas o
era algo que ya estaba existente?
(18:10)
ER: Es parte de la reforma de salud, es parte del gobierno. Entonces nosotros...es parte de la política
del gobierno de estado de llevar la salud a la comunidad. Entonces nosotros como
programa...nuestra obligación es también integrar en esos equipos lo que es el programa de Chagas.
Para dar respuesta a nivel comunitario.
PR: Y esa reforma, cuándo se hizo?
MG: Es en proceso
ER: Es todavía, sí, en proceso. Comienza el 2009 el 2010
PR: Ok. Así que el programa de Chagas empezó y cuando estaba funcionando algo diferente
también pasó y...
ER: 2003 al 2009 funciona diferente. 2009 a 2015 es la segunda fase que, con la reforma de salud,
nosotros tenemos que también adaptarnos a esa reforma...que viene a dar respuesta, como te
menciono, a la parte comunitaria que es también parte del abanico de oferta de salud que llevan
nuestros equipos a nivel comunitario.
PR: Y qué era la razón de esa reforma. O sea, quién lo empezó?
(19:34)
ER: Bien, la idea es de acercar más la salud a las comunidades y eso facilita más este tipo de
proceso. O sea, ya no esperar que la comunidad venga a mí...o sea es una manera de trabajar
preventiva. Entonces de esa manera evito que mis hospitales estén congestionados con mucha gente
que por una consulta (pueda) darse... por una gripe, por otro tipo de...más sencilla (que pueda
dar?)...detectarse en campo, ya no me está congestionando los hospitales. Y eso facilita. Y se evalua
también a que ellas atenciones que necesitan ser referidas, se refieren a ya un nivel mayor para la
atención respectiva. Entonces eso nos permite incrementar el abordaje comunitario, nos permite
incrementar (la boca de?) activa, nos permite también una inspección, mayor inspección de
viviendas a nivel comunitario
PR: Y en la reforma general, se [utilizaron] las experiencias del programa de Chagas en esa
reforma?
(20:51)
ER: No. El programa ya tenían ellos. A nivel político la idea es acercar, como te digo, la salud a las
comunidades. Entonces como tiene un abordaje más comunitario, entonces lógicamente se adaptaba
a nuestros objetivos, intereses de ser comunitario como la enfermedad, aunque la OPS le llama
desatendida, para nosotros no es tan desatendida porque la (venimos?) dando un abordaje. Somos el
único país en América de haber eliminado un vector. En 2010 Fuimos declarado libre del vector
Rhodnius Prolixus. Ahora solamente tenemos la Triatoma Dimidiata, tenemos lo que es el...por ahí
el (Rhismani?) o la Triatoma Nitida pero no son buenos vectores. Entonces esto el sistema, el
abordaje, el sistema de salud nos ha permitido también ir mejorando en esto. Todavía tenemos que
mejorar en el abordaje.
PR: Pero en su opinión, la manera de hacerlo era algo que ya tenían en el sistema de salud: O
sea...la manera de acercarse a las comunidades era algo que ustedes ya sabían que iban a hacer? No
era algo que se introdució desde afuera?
(22:20)
MG: Es que anteriormente se manejaba la figura de promotores de salud...es hacer una persona que
estaba en las comunidades y que hacían el papel de los equipos comunitarios, pero sólo era un
promotor para un área grande. En cambio, con esta reforma que el nuevo gobierno estableció, esos
equipos comunitarios tienen una mayor cobertura. Entonces ya no sólo está el promotor rural en un
área geográfica grande, sino que hay equipos... con los cuales se divida el trabajo, y se logra una
cobertura mayor de la población. Pero anteriormente se hacía el trabajo comunitario a través de los
promotores rurales de salud.
(23:05)
ER: Mira, Chagas es comunitario. Nosotros ya veníamos haciendo de manera...con menor
cobertura. Cuando se le inyecta la nueva reforma, la reforma de salud, lógicamente es un
incremento de recurso humano. Entonces eso lógicamente hace que incremente nuestras acciones de
abordaje en campo. Pero nosotros, como ya lo mencionaba la Dra., ya había una cantidad de recurso
humano, promotores de salud que se venía haciendo este tipo de trabajo.
MG: Por otro lado, también es importante mencionar la promoción que se ha hecho de la
enfermedad y ahí, sí, tuvo bastante que ver la JICA porque ellos nos facilitaron mucho con los
personas voluntarias que venían promocionar en las communidades la enfermedad. Entonces la
gente conocía mucho de la enfermedad...entonces eso generó de que las personas, si veían chinches
en su casas, las llevasen a las unidades de salud para que las examinaran y de esa forma ya nos da
cuenta que cómo estaba la comunidad. Entonces hizo como en dos vías la necesidad de reportar,
verdad? Y que les fueran a hacer a ellos también sus acciones. Pero la promoción que se hizo en
todo este periodo que la JICA estuvo fue bastante, bastante intenso.
PR: Entonces, en su opinión, lo más importante de la JICA era...la conscientización del tema y la
manera de reportar los hallazgos de chinches?
(24:51)
ER: Es que con la JICA tuvo una ventaja...hasta nosotros tuvimos que aprender mucho como nivel
rector. El hecho que nosotros somos a nivel mundial un programa exitoso en Malaria. De 160.000 –
150.000 casos que teníamos antes hoy tenemos 8 [mil]. La experiencia nuestra era en la cuestión de
rociado para control del vector transmisor de la Malaria. Chagas lo hacíamos pero de una manera
tan directa y aplicamos la misma técnica de rociado que de Malaria. Cuando vinieron esos expertos
japoneses y nos dicen ”No. Es diferente”. Ya comenzamos nosotros a aprender cosas que por
arraigo traíamos. La ventaja que hubo con la JICA es que nos cambia, no solamente ver al vector,
sino que ver al programa de una forma integral. Y una de esas era fortalecer el recurso humano en
cuanto al conocimiento. 2, es ver la parte inclusiva ”No soy médico, pero (veo?) la parte clínica,
veo el tratamiento”. Vemos la parte de educación y promoción, y lo que la Dra. menciona es: ese
abordaje integral que se le hizo, no solamente fortalecimos la parte de control del vector, sino
que...laboratorio...se fortaleció el 100% laboratorios a nivel nacional. Entonces ese abordaje...la
parte...no teníamos promocionarles...por ejemplo ese que está acá [peger?]. No teníamos
promocionarles de Chagas...había de Dengue, había de otro tipo de patología. No así de
Chagas...portafolios/rotafolios u otro tipo...trípticos...otras cosas de material educativo. Ellos
vinieron, le metieron plata a la parte de esta técnica de la estructuración de material educativo. En
televisión hubo mucha divulgación de lo que el ministerio estaba haciendo. Entonces todo esto vino
a fortalecer lo que es el abordaje integral. No solamente una sola línea, sino que seguimos las
diferentes líneas.
MG: Y no solamente comunitario, sino que a los diferentes niveles de atención. O sea, desde el
nivel rector que somos nosotros, a nivel ministerial, la parte de regiones, la parte de SIBASI –
personal de SIBASI, hasta llegar a la comunidad... Todas de diferentes escalas...de alguna forma
tuvimos apoyo académico...podíamos decir, en el sentido de conocer más de la enfermedad.
ER: Otra cosa que nos fortaleció era...las reuniones de intercambio de experiencias...hicimos
intercambio de experiencias.
PR: Entre los diferentes países?
ER: A nivel nacional...que del oriente venían al occidente ver cómo abordaban Chagas. A nivel
centroamericano fuimos...con la Dra. fuimos a ver cómo...a (dar?) nuestras experiencias. De
hecho...fuimos considerado el mejor programa...El Salvador...de unos (cientos – nogle hundrede)
programas o 200 programas de la JICA a nivel mundial...el mejor, exitoso. Entonces nosotros le
hacíamos la broma al embajador que nuestro pecado es haber trabajado bien. Entonces ya
nos...decían ”ustedes solo pueden”...lo cual...el mismo sistema...el sistema de salud nos permite no
bajarnos del tren...este de Chagas porque ya la gente de mandante...entonces nosotros tenemos que
estar atentos.
PR: También estaba pensando...ustedes mencionaron la integración entre las diferentes disciplinas.
También es algo que...o sea esa manera de trabajar – es algo que también se puede utilizar en otros
temas de salud [que] el programa de Chagas?
(29:11)
ER: Para nosotros Chagas fue un ejemplo para el abordaje porque...para hablar de Chagas...por
ejemplo nosotros...Chagas, lo vemos desde el punto de vista legal también. Hicimos un decreto
legislativo donde se declara un día nacional de Chagas. Entonces esto también se ocupa como
modelo para otras patologías...ejemplo Dengue, ejemplo Leihsmaniasis (?), malaria...bueno con
Malaria ya teníamos un terreno ganado que esa experiencia, también la fortalecimos en lo que es
Chagas hoy...ya la estrategia de Chagas es más rica, es más...con mucha experiencia en todo los
campos de abordaje. Lo cual se pone en práctica para las otras patologías...Y como somos los
mismos. Nosotros dos [ham og MG]... a nivel que...en otros países puede haber mucha gente en
abordaje...venía de Guatemala, vinieron de Guatemala, vinieron de Honduras vinieron acá a ver
cómo estabamos gerenciando, y esperaban ver un edificio, esperaban ver un montón de gente,
abordando Chagas – No.
PR: Pero eso, lo hace más fácil...que es un equipo más pequeño...que no hay que coordinar con más
entes...?
(30:50)
ER: Sí
MG: El problema es que nosotros somos los mismos para todas las [enfermedades] vectorizadas, no
solamente para Chagas. Entonces eso nos quita...nos quita tiempo para...algo que (a veces) está...no
planificado hacer...por ejemplo ahora lo de Malaria. Estamos prácticamente el 100% con Malaria,
pero hay cosas que no podemos descuidar, pero de alguna forma no lo podemos lograr. Pero lo que
nosotros quizás hemos aprendida es la parte organizativa del proceso de atención de la enfermedad
de Chagas. Porque desde el nivel rector hasta el nivel local, verdad?, tenemos una línea de mando y
de acción acuerdo a lo que (se va a) hacer. Entonces eso, sí, ayuda bastante. Ya no se trabaja de una
forma desordenada, sino que bien planificada.
PR: Y también lo que mencionaron lo de los tabuladores...que se utilizan para...
MG: Análisis.
PR: Análisis, exactamente. Esa forma de trabajar también se utiliza en otros temas ahora?
ER: Sí. Se utilizan en Dengue, Malaria, Leishmaniasis. Inclusive hoy, con los fondos que nos van a
dar que es del Fondo Mundial vamos a fortalecer el sistema para hacerlo más...más eficiente todavía
porque vamos para adelante. O sea, a nivel centroamericano, somos el único país, quizas, que tiene
sistematizada toda la información operativa...epidemiológica y entomológica. Por ejemplo, si ando
en Dinamarca, y (allá?) me ocurre hacer el informe de una vectorizada, yo me meto al sistema, y lo
hago. Entonces, eso facilita los procesos de análisis e interpretación. Entonces nosotros...tú hacías
una pregunta ”Cómo el ministerio asumió las responsibilidades de la JICA?”
(32:59)...realmente no era una responsibilidad directa de la JICA. Era una responsibilidad como
nosotros, como país...entonces fue más fácil porque nosotros tenemos...hay una mística de trabajo a
nivel...bueno, comenzando de acá que nos gusta lo que hacemos. Ya en campo es igual, la gente que
hace Chagas, le gusta el trabajo.
PR: Y entonces era más como...que la JICA no tenían las responsabilidad pero más era una
asesoría...
MG: Apoyo
ER: Asesoría
MG: Asesoría y de apoyo
(33:36)
ER: Por ejemplo, para decirte, que nosotros a través de la JICA...por ser un ente internacional tiene
más facilidades a nivel político también...lo cual...él que es Presidente de la república hoy, fue el
Ministro de educación el gobierno pasado. Con él se firmó un convenio de cooperación con el
Ministerio de Educación. Entonces eso nos permitió hacer una abogacía política...posicionar el tema
de Chagas a nivel político. Y eso, también con la JICA, se hizo un trabajo muy fuerte el 2014-2015
que es la sistematización de las experiencias de vigilancia y control de Chagas...hay un libro de...se
sistematizan todas las buenas, no sé si ya lo vieron?
PR: Sí. De los 4 países...
(34:34)
ER: Sí, sí. Entonces eso nos permite a nosotros también...ahí solamente se pusieron las
más...digamos...todas son relevantes...pero eso era como más político, técnico el abordaje con el
ministero de educación que hoy es presidente de la república. Entonces esto nos permitió también
asumir la responsabilidades en todos los pilares de lo que es Chagas. Como te decía, vigilancia
epidemiológica – tenemos sistema único de información donde tributan todo el sistema nacional de
salud que está el Ministerio de Salud, el Seguro Social, está bienestar magisterial, está la gente del
batallon de sanidad militar, todo el sector privado ahí tributan en el sistema para detectar casos
agudos.
PR: Y cómo se detectan los casos agudos? Es que la gente viene con síntomas o es por las encuestas
diarias?
(35:40)
ER: Fíjate que hay veces...hay veces que es por...a través del tiempo es por la experiencia que
nuestra gente en campo tiene. Ejemplo, ven un signo de Romaña, la gente sabe que es eso. Entonces
ya lo remiten al establecimiento de salud. Ya le ven el signo, que no es muy común, pero ahí es
donde se detecta el caso. La otra situación es por demanda. Llega el paciente, se siente mal, ha sido
picado, sienten un chagoma o un...entonces esos llegan al médico, y con temperatura, con todos los
signos y síntomas que le hacen concentrado de Strout, y es donde se detecta el caso.
PR: Pero como Chagas a menudo es asíntomatica, o sea hay problemas con...
ER: Sí, definitivamente es parte también de los retos que va a tener el ministerio fortalecer el
recurso médico también para la detección temprana de los casos agudos. Porque tenemos un
promedio de 1.000 a 1.100 casos de crónicos en bancos de sangre que nosotros tenemos una ley de
banco de sangre, una normativa que rige a los bancos de sangre de público como los que son
privados...entonces es ahí donde tenemos los...dos sistemas de detección de casos que uno
lógicamente ya es histórico por el donante de sangre ya es histórico.
PR: Y también...ustedes mencionaron el convenio entre los ministerios de salud y educación. Y en
su opinión, se pueden utilizar las experiencias de ese convenio para otros temas de salud también...o
ya se utilizan?
(37:33)
MG: Ya se utilizan en alguna forma porque también de Dengue se habla...porque el convenio es
para que los estudiantes dentro de la currícula de los grados de estudiantiles esté el tema de Chagas.
Y se habla sobre Chagas a los niños. Y también se habla sobre Dengue. Son las dos patologías
prácticamente que...se han tomado a nivel de ministerio de educación. Y además de la currícula,
también aquí se maneja una escuela de padres. Donde se reune cada cierto tiempo a los padres de
los centros escolares para hablarles de temas diferentes, verdad?, y dentro de ellos también se
incorpora la parte de Dengue y de Chagas de acuerdo a la época del año.
PR: Y en el tema de...hacer el tema más conocido...también por ejemplo los ECOS, también
colaboran con otras organizaciones de la sociedad civil [u] organizaciones religiosas o algo así?
(38:30)
[ER’s telefon ringer, han tager den og siger at der lige går nogle minutter]
MG: Sí, es parte de las actividades en todos los niveles. De las regiones a SIBASI hasta los niveles
locales...llamamos ”niveles locales” a todas las unidades comunitarias de salud familiar. Ellos
tienen obligación de hacer coordinaciones con otras entidades del área donde están. Y de acuerdo al
nivel, a la complejidad del nivel, por ejemplo el SIBASI es a nivel departamental...ellos hacen
relaciones y coordinaciones con los alcaldes, con instituciones como ”ANDA” (? 39:05),
gobernación, dependiendo del área. Si son a nivel locales con los centros escolares, con la unidad de
salud de mayor complejidad. O sea que siempre hay coordinaciones a niveles diferentes.
PR: Pero también colabora el programa con organizaciones o actores que no pertenecen al sistema
de salud?
(39:30)
MG: Sí, pues, sí. Por ejemplo, la alcaldía. No pertenece al sistema de salud y es parte de las
actividades que se...que coordinan con ellos para hacer actividades específicas
PR: Otra cosa. Hemos leído que cuando se detectan los casos agudos, los doctores [tienen] que
indicar el tratamiento con el Nifurtimox o Benznidazole. Y quisiéramos saber si siempre está
disponible la medicina, o si a veces hay problemas con la accesibilidad a la medicina?
(40:16)
MG: Fíjense que sí, la medicina siempre...existe. Es muy raro que nos quedemos sin medicamento.
El año pasado el __ fue un problema que hubo porque... a los crónicos antes no se les daba
medicamento por norma...ya estaba escrito en la norma que al paciente crónico no se le diese
medicamento...sólo al paciente agudo y el crónico se trataba de acuerdo a su patología que tenía
posterior a su enfermedad. Pero nosotros recibimos unas conferencias muy interesantes donde se
habían hecho estudios e investigación en las cuales los pacientes crónicos cuando se les daba el
medicamento, mejoraban notablemente sus funciones; disminuía el parásito que tenía a nivel
detegido, y entonces ellos mejoraban al nivel...Por ejemplo, los cardiacos (?) mejoraban
notablemente sus problemas cardiacas...entonces eso generó, con un poquito de __ , en el sentido a
que la gente ya empezaba a sentir ”tenemos que darles a los crónicos porque mejoran...”. Hubo un
momento que a los crónicos...algunos pacientes crónicos se les empezó el tratamiento...hubo un
poco de desfase de medicamentos...pero generalmente siempre para los agudos siempre tenemos.
(41:31)
ER: Todos medicamentos...nosotros recibimos es de carácter donativo de OPS, de PAHO. No
hemos tenido un desabastecimiento, sino que tuvimos un susto, digamos, porque nosotros, la norma
ya la cambiamos. Antes solamente se podía tratar a menores de 15 años. Ahora nosotros, debido a
los estudios que nos han presentado y demostrado...que el crónico, aunque no cura...pero hay una
mejoría en cuanto a...
PR: Las síntomas?
ER: Perfecto...entonces eso nos obligó a nosotros a poner en la norma de tratar al 100% de crónicos
con el respectivo seguimiento clínico. No solamente entregarlo como cualquier medicamento, sino
que es tratamiento estrictamente supervisado – uno. Dos: También nosotros hemos hecho estudio
con la JICA, también la JICA nos dejó esa gran...esa gran escuela de la parte investigativa.
Tenemos mucho trabajo publicado por ellos...que hemos publicado en conjunto. Lo cual...hicimos
un estudio de transmisión congénita donde demostró que hijos nacidos de madres chagásicas traen
una buena posibilidad...lógicamente de la transmisión directa. Y eso también nos obligó a cambiar
la norma de tamizar al 100% de madres embarazadas...o sea, no estaba normado [antes]...pero, sí
está normado lo que es, en la nueva norma, el tamizaje al 100% de madres embarazadas.
PR: Perfecto. También tenemos unas preguntas sobre el rociado de casas. [Saben ustedes] con qué
frecuencia se realiza el rociado por el momento? Más o menos
(43:26)
ER: Dura tres meses. O sea, que nosotros...el rociado tiene tres condiciones para poderlo ejecutar.
El rociado, por ejemplo, es...el primero es...concreto riesgo lógicamente. Ejemplo, uno es si aparece
un caso agudo. Y si el caso agudo demuestra que el caso es autóctono del lugar, se hace una
investigación entorno al caso y si se detecta el vector, se hace el rociado al 100 % del área o el
caserío donde (procede) el caso. También se hace una aplicación del rociado en aquellas localidades
que tengan índices arriba del 5% porque la norma dice...abajo del 5% es bajo riesgo y arriba del 5%
alto riesgo. Esto es otra condición para la cual se puede...uno: programar una localidad para el
rociado respectivo. Esto se evalua también cada 6 meses, la presencia del vector...o sea, cada 6
meses hay una evaluación para verificar si hay presencia del vector. Si hay presencia después del
rociado, se hace un rociado selectivo y ya no es a toda la comunidad, sino que selectivo donde hay
riesgo. Por ejemplo, viviendas contruidas de bajareque, o sea un tipo de material, o las construidas
de adobe que es un ladrillo sin cosimiento. Entonces eso hace que tenga el hábitat perfecto para...el
vector transmisor del Chagas.
PR: También se hacen esfuerzos para mejorar las condiciones de las viviendas? O sea, las paredes,
los techos...
(45:01)
ER: Nosotros como ministerio hacemos solamente coordinación. O sea, recomendamos y también
coordinaciones con respectivas comunas u organismos no gubernamentales, las ONG que se
dedican a esto. O con los gobiernos municipales. O sea...o recomendamos dentro de nuestras
posibilidades en campo que (se dedicen a hacer...) rellenar, repellar la vivienda para esta...
PR: Y otra cosa...concerniente al rociado...cuando se empezó el rociado...o el programa de Chagas.
Era fácil difundir las técnicas del rociado o había unos problemas relacionado a eso?
(45:48)
ER: El problema que teníamos era cantidad de equipos. No teníamos equipos. Vino la JICA y nos
aportó una cantidad de equipos de rociado. Para...a nivel comunitario. El problema, como te
mencionaba, al principio era que nosotros somos expertos en la cuestión de Malaria, en la cuestión
del rociado que lleva una técnica: la distancia de la boquilla a la pared, la cantidad de ingrediente
activo por metro cuadrado. Quieríamos hacer lo mismo para Chagas, pero ahí: no. Por el tipo de
vector...la técnica diferente. O sea, acercar la boquilla donde existen perforaciones, donde existen
grietas, teníamos que acercar la boquilla. O sea, cambiamos la técnica del rociado para lo que es
específico de la enfermedad. También Chagas nos permite y nos ha permitido tener una mayor...se
están rociando un promedio de 23.000 casas al año. Lo cual nos permite la participación
comunitaria en el rociado. No solamente hacer el rociado el recurso de salud, sino que los ECOS
tienen organizadas comunidades que se lleva el equipo, el insumo químico, se capacitan y ellos son
los que hacen el rociado.
PR: Voluntarios?
ER: Voluntarios. O sea, no solamente salud, sino que hay una socialización, hay una
democratización, para decirlo así, de lo que es la acción operativa. Ya no es exclusiva del ministerio
de salud. Uno, lo que nos favorece es la técnica de rociado...no solamente una técnica (decurada, de
curada?), de aplicación del producto, sino que con todas las medias/medidas de bioseguridad, con la
capacitación y la evaluación entomológica...para ver el impacto de la...el rociado en la comunidad
(47:39)
MG: También se metieron los folletos de...los vieron?
PR: Hay dos, no?
ER: Hay dos lineamientos [versión popular, ]
MG: Eso ha...es con el objeto de se estandaríce la metodología del rociado.
ER: Fuimos los primeros en hacer eso. Porque? Porque nuestras normativas de...de la dirección de
regulación que es la que nos rige para hacer documentos regulatorios, no permitían ese tipo de
documentos. Pero nosotros decimos, alegamos, bueno, si hay gente que no puede leer...hay gente
con una capacidad de interpretación un poco menor. Entonces es mejor que unos dibujos...que eso
orienta más a el que va a involucrarse en el trabajo operativo.
PR: Y los voluntarios que hacen el rociado, cómo son seleccionados? O sea, se ofrecen como
voluntarios...o?
(48:44)
ER: Hay una gama, una diferencia, hay diferentes. Hay unos que se ofrecen o que tienen
experiencia en el campo agrícola por lo...hacen aplicación de rociado en que...en los cultivos...ellos
dicen ”yo lo hago” o también son seleccionados en...reuniones que se hacen en la comunidad donde
se hace la socialización del problema y esta situación..entonces ellos identifican quien puede
hacerlo y se seleccionan.
MG: Algunas comunidades (tienen/sirven?) directivas [ledelse, bestyrelse] de salud y esas
directivas de salud son las que retoman la promoción incluso de la enfermedad...se recuerda ahí en
Sonsonate donde fuimos con el embajador de la JICA...el señor [ikke fra JICA] pertenecía a una
directiva y él estaba tan consciente de la situación que promocionaba, por ejemplo...porque en su
casa había cambiado su forma de vida, digamos, para mejorar las condiciones de salud. Y eso lo
promocionaba...así que la comunidad también se encarga de....a través de la organización
comunitaria.
PR: Al final tenemos unas preguntas sobre los beneficios de la colaboración con la JICA. En su
opinión, cuáles han sido los mejores beneficios del involucramiento de a JICA en el control de
Chagas?
(50:17)
ER: Yo pienso que numerarlos sería injusto...los beneficios que nos han dejado ellos. No tiene un
nivel de importancia...todos tienen un nivel de importancia para nosotros sumamente altísimo.
Porque ellos nos dejaron un beneficio, como te mencionaba, en 5, 6 pilares de abordaje de cualquier
vectorizada. Ejemplo, vigilancia epidemiológica, vigilancia entomológica en sus dos fases:
vigilancia entomológica comunitaria y la vigilancia entomológica activa que es la nuestra. La pasiva
no es [nuestra]. La otra situación es la parte de...las situaciones de investigación...el bagaje, la
experiencia en cuanto al...a la investigación que nos han dejado ha sido increíble...que no
solamente...comenzamos con Chagas, estamos trabajando fuertemente en investigación en Dengue,
estamos trabajamos fuerte en investigación en los químicos que estamos utilizando. Entonces eso
nos fortaleció. El otro beneficio que dejó la JICA es la parte del recurso humano que es invaluable
en cuanto a conocimiento, actitudes y la práctica de nuestra gente. Porque pueden (sostener) mucho
conocimiento de Chagas pero al momento de hacer una práctica... ya no los hacemos ”porque no me
gusta”...(hay) ese motivo... pero en estos casos ellos nos dejaron un fuerte legado en la parte de
conocimiento, organización y planificación.
PR: Y es algo que se puede utilizar en muchas temas?
(52:10)
ER: O sea que esta o de Chagas para nosotros ha sido trazador [udkast] para otras patologías...y
como somos también los que vemos (?), esta situación...nos facilita esto
PR: Y otra cosa. En los últimos años desde el 2011 cuando la JICA terminó su parte, se ha
cambiado la estrategia del control de Chagas o sigue la misma?
(52:43)
ER: (ha ido) fortaleciendo...teniendo mayores...más actores. O sea, como te decía...los pilares que se
aborda Chagas van a ser los mismos: vigilancia epidemiológica, te repito, epidemiología,
entomología, control y la parte de diagnóstico y tratamiento, vigilancia epidemiológica y la
participación comunitaria es el común denominador para las otras patologías. Se ha ido
fortaleciendo a medida también que otras patologías nos han permitido también ir abriendo campos
en otras áreas que también nosotros, como responsables del área, metemos el tema de Chagas en
cualquier momento, situación que se nos presente. Ejemplo, a cambio de tener una...con los
militares tuvimos una jornada un fin de semana con pacientes crónicos de Chagas que...estamos
hablando de un tema clínico y terminamos hablando del vector; donde viven nuestros soldados,
cómo viven. Entonces son situaciones que nos permiten ir ganando más...más fuerza de trabajo en
los diferentes niveles. O sea que eso...Chagas ha sido fundamental para todas las patologías
PR: Y también...en su opinión, cuáles son los mayores desafíos [por] el momento de la prevención
de Chagas?
(54:27)
ER: Bueno, los mayores desafíos también tenemos...o sea hay varios...nuestro mayor desafío es
involucrar a las escuelas formadoras del recurso humano para efecto de...que lo dediquen más
tiempo a lo que es la parte Chagas. Desafíos en diferentes áreas, por ejemplo, tenemos desafíos en
la vigilancia epidemiológica...El desafío, que te mencionaba, es continuar fortaleciendo el sistema
único de información para efecto de....como estos sistemas son perfectibles...lo otro es: ir buscando
más allá de lo que tenemos. Por eso mencionábamos que otro desafío es una revisión permanente de
lo que es el sistema de información...el otro desafío que tenemos es en la parte de vigilancia y
control de vectores...que es potencializar más a las diferentes disciplinas en lo que es la acción de la
vigilancia y control del vector, mantener activa la vigilancia entomológica a través de las
comunidades, es otro gran desafío.
PR: Y por qué es un desafío? Hay que hacer más talleres o...
(55:55)
ER: Ampliar más, tener mayor...tenemos a nivel nacional una buena vigilancia pero necesitamos
también ir fortaleciendo este punto.
PR: Otra cosa. Hemos leído que el rol de la OPS ha sido asesoría técnica. Y cómo han participado,
la OPS?
(56:28)
ER: OPS cuando estaba la JICA, era...un ente también técnico...para nosotros referente...lo cual,
debido a multiples trabajos que estamos haciendo en diferentes patologías...tenemos un mayor
acercamiento para el abordaje técnico...mayor apoyo técnico, mayor apoyo financiero
también...aparte...que bárbaro el dinero, no?...sino, por ejemplo, designan unos fondos para
capacitar, fondos para evaluar. O sea eso a nosotros nos facilita...nos fortalece, ya que vemos de una
forma oportuna que son las acciones o medidas que tenemos que ir corregiendo o reorientando.
Entonces OPS para nosotros lógicamente es un referente que nos apoya...se involucra en el trabajo
diario de nosotros en lo que es control de vectores en Chagas y otras patologías como Dengue,
Leishmaniasis...
PR: Perfecto. Bueno, al final sólo quisiéramos saber si hay algo importante, en su opinión, sobre lo
que no hemos preguntado o algo que ustedes desean añadir.
(57:54)
ER: Pienso que...a hablar de Chagas, como te digo, es algo que...con temas bastante interesantes, ya
que...seguimos en deuda nosotros con unas cosas que tenemos que seguir investigando...a nivel
hospitalario, a nivel comunitario para efectos de ir estrechando más. Bueno, con OPS tenemos
pendientes ciertas publicaciones...hemos hecho trabajo con ellos con respecto a lo que es la
caracterización de la transmisión de Chagas a nivel del occidente del país....
MG: Y quizás las necesidades sentidas en el país es el apoyo financiero en cuanto a la parte de
promoción porque...para la promoción quizás sentimos el bajón...con la JICA tuvimos un gran
apoyo en cuanto a todos esos afiches, rotafolios, papelería etc. Entonces ya todo eso disminuye por
la falta financiera. Entonces eso, sí, se necesita de los cooperantes que nos apoyen con eso ahora.
Hablamos con Ken Hashimoto de que nosotros...lo que pedimos no era el pescado, sino que nos
enseñen a pescar..__ una oportunidad. Y realmente ese fue lo que se logró con la JICA: Ellos nos
trajeron mucho conocimiento para poder avanzar. Pero también necesitamos como país ese apoyo
financiero para la parte de promoción.
ER: Lo que menciona la Dra. también es que es bueno importante recalcar...somos...funcionamos
sin fondos...sólo con fondos de gobierno. No somos...no hay una...un organismo de cooperación...sí,
como pueden tener en otro país...hay un fondo de....en Sudamérica mucho apoyo de parte de la
Fundación Española...en Guatemala...pero nosotros no. Sólo con fondos de gobierno.
PR: En Honduras hay fondos de Canadá.
ER: Canadá...
____[alle taler lidt i munden på hinanden et øjeblik]
ER: Sólo para hacerte una idea. La semana recién pasada fui, o hace 15 días, fui a una reunión en
Costa Rica. Teníamos que ir nosotros [ham og MG] pero no pudimos ir, fue otro compañero,
hicimos la presentación...esto somos nosotros...El Salvador [peger på kort?]. Tenemos la frontera
con Guatemala acá, es donde tenemos la parte del occidente del país y aquí tenemos lo que es
Jutiapa (?), Concepción (Mita?) de Guatemala, acá tenemos la parte...mayor frontera con
Honduras...donde nosotros hemos hecho estudios entomológicos para buscar el Rhodnius Prolixus
en nivel nacional y no encontramos. Entonces, estamos divido en 14 departamentos, 262
municipios...
MG: 5 regiones.
ER: Sí. Como estamos...esto es...como está el país geográficamente distribuido 14 departamentos,
262 municipios, tenemos el sistema de salud como es que está estructurado...tenemos 5 regiones, la
región occidental, la región central que es la Libertad y Chalatenango, la region metropolitana que
es donde estamos lo que es San Salvador, la región paracentral, y la region oriental que abarca 4
departamentos. La JICA se ubicó en estos tres [peger], se ubicó en este, y se ubicó en Usulután, San
Miguel y Morazán...7 Departamentos...Tenemos 5 regiones, 17 SIBASIs, como te mencionaba...
(1:02:09)...Aquí estan los equipos comunitarios de salud que son...como ves...toda esta cantidad de
puntos [på et kort] es donde nostros hacemos la vigilancia entomológica...es donde hacemos la
vigilancia entomológica comunitaria,
PR: Y hay 480 de esos equipos [ser på hans papir]?
ER: Sí...tenemos 700...sumados 700. Acá está el detalle...Tenemos hogares de espera materna...para
que ellas madres que son hospitalizadas en los establecimientos de salud que tienen criterio de
riesgo...con cuestión de aborto es cuando también se aprovecha hacer diagnóstico de Chagas.
Tenemos 184 dice aquí...pero tenemos 189 laboratorios...toda esta cantidad de laboratorios están
capacitados para el concentrado de Strout, para el diagnóstico de Chagas.
PR: Y cuándo se empezaron esos laboratorios? Antes de la JICA....?
(1:03:15)
ER: Estos están de...antes de la JICA. Pero se han venido incrementando con año. Entonces
tenemos laboratorio nacional de referencia que...para qué nos sirve el laboratorio nacional de
referencia? La norma dice que todos estos laboratorios hacen concetrado de Strout. Ellos tienen que
mandar a control de calidad el 100% de los positivos y el 10% de los negativos al laboratorio
nacional de referencia para verificar la certeza en el diagnóstico. Entonces eso nos garantiza la
calidad en los laboratoristas a nivel nacional. Todos ellos tienen la capacidad de hacer diagnóstico
de Chagas. El 100%. A nivel histórico tenemos...aunque tenemos más años para nivel de
presentación...solamente tenemos los grupos (de edad) que han sido afectados..2013, 2014 los
grupos de edad que tenemos afectados con Chagas agudo...donde tenemos la transmisión...la
transmisión de Chagas agudo se centra en el occidente del país...te recuerdas, te dije que aquí [tæt
på den vestlige del af ES?] tenemos Guatemala y no detectan casos...no tienen casos...nosotros sí.
Es...parece bien risible...está la frontera. Logícamente no hay ni un muro, no hay nada. Acá a 50
metros, casos de Chagas, y de aquí por allá, nada. Y hay vector. Pero es por....
PR: La capacidad de detectarlo?
ER: Sí
(1:04:56)
ER: Entonces tenemos el 2011, mira como tenemos la transmisión [viser kurve?  evt tjek slide fra
interviewet] en el occidente..donde tenemos la transmisión en el 2012 lo mismo...2013 y 2014
tenemos también transmisión donde hay puntos...en otras parte del país...donde tenemos...hasta la
semana 44, 2015...no lo tenemos la transmisión concentrada en el occidente del país...acá estos son
Chagas agudo...acá tenemos la seropositividad en..de (agentes infecciosos) en bancos de sange en
El Salvador 1997 a 2015. Este trabajo ya se publicó en el Instituto (Fiocruz?)...Acá 2015 tenemos
1.6. O sea se ha logrado sostener, mantener con la seroprevalencia...quiere decir que de 100 casos,
de 100 donantes, 2 están saliendo positivos de Chagas. Y tenemos, fíjate, Chagas sumamente arriba
de VIH, de Hepatitis C, Hepatitis B. Esto es bancos de sangre...Y tenemos una vigilancia
entomológica comunitaria...es...quiere decir que la población lleva las chinches al trabajador de
salud. Y todo esto genera una acción...Cómo está la distribución del vector? Lo tenemos en 262
municipios...acá está el tipo de vector que tenemos...el amarillo es donde está el (Ritmani?) que fue
detectado en 2010...y acá en punto rojo, Sonsonate, lo que es Nitida ...Pero el Triatoma Dimidiata
está en los 262...acá tenemos las viviendas infectadas desde el 1997 hasta el 2015...que esto lo saco
del sistema...rociado de viviendas [han viser noget]...cuántas viviendas han rociado en
2015...municipios donde se han rociado...lo que me preguntabas...están los desafíos, los desafíos
van en las diferentes líneas: vigilancia epidemiológica, en vigilancia y control del vector – cuáles
van a ser mis desafíos?, la capacidad de diagnóstico, cuáles serán? Y acceso al tratamiento, cuáles
van a ser mis retos?, en promoción de la salud...y en recurso humano...cuáles son los próximos
pasos que tenemos que hacer...socializar la norma que ya la terminamos...ya está terminada
solamente falta socializarla...congreso de Chagas...(información/educación) en el marco de
enfermedades desatendidas...o sea...al nivel político sólo tenía la reforma 8 ejes...8 ejes tenía la
reforma de salud. Pero a partir de este año, le integraron uno que es el eje de salud ambiental.
Entonces es también integrar el tema de Chagas en el marco del noveno eje de la reforma de salud.
[Det næste stykke er small talk og ikke specielt vigtigt for noget..men bagefter kommer der
lidt mere godt]
PR: Perfecto. Nos puede pasar esa presentación? Tengo un USB acá...
PR: Por cierto, una cosa que olvidé mencionar es que nuestra investigación es para..sirve para
nuestra tesis de maestría así que no es algo que intentamos publicar. Pero en el futuro, si tenemos la
oportunidad de publicarla, vamos a volver a pedirle su consentimiento. Y otra cosa
también...ustedes si lo desean, pueden quedar anónimos en la investigación. O sea, nuestra asesora
recomendó que todas las personas a las que entrevistamos queden anónimos en la investigación.
ER: Por qué se eligió Chagas?
PR: De hecho un poco por casualidad porque nosotros empezamos investigar el tema
de....medicamentos para enfermedades desatendidas...y encontramos la enfermedad de Chagas y yo
estuve en Bolivia hace un año y también escuché de la enfermedad allá...así que empezamos a
investigar un poco, y encontramos [comprender, enterarse de] que hay un programa de los Médicos
Sin Fronteras en Bolivia y también encontramos los programas de Centroamérica. Y por eso había
muchas cosas para investigar y también hemos entrevistado a una persona de la MSF. Y
empezamos a leer mucho y después de un tiempo, para nosotros es muy interesante, no? Cuando se
dedica a algo, se hace más interesante y ahora ya hemos trabajado con este tema por 5 meses así que
ahora nos interesa mucho saber más sobre todos los esfuerzos en los diferentes países.
(1:11:10)
ER: Que bueno. Yo estuve en Bolivia también viendo el tema este.
MG: Y cuando terminen la tesis, nos difunden una copia
PR: Sí claro. De hecho ya hemos hablado con el Sr. Hashimoto también....
ER: Ken Hashimoto?
PR: Sí. Es que buscamos artículos de Chagas y hay una cosa que se llama ”la biblioteca pública de
ciencia” [PLOS] en el internet. Y buscamos artículos allí y encontramos a unas personas que han
escrito sobre el tema...y encontramos al Sr. Hashimoto y él nos facilitó los datos de contacto y todo
y también vamos a hablar con él en enero y también hay otro experto japones que ha trabajado en
Nicaragua.
ER: Es este...Jiro?
PR: No, se llama Kota Yoshioka.
ER: Ahh, Kota...se casó con una nicaraguaguense (?)
PR: Ahh no sabíamos eso...de hecho nos contó que va a regresar a Nicaragua en Enero también
para...
[Herfra begynder det at blive interessant igen]
(1:12:37)
ER: Y ellos...el tema continua [en Nicaragua] pero es porque...como que no visualizan la misión
que el país esté preparado para...soltarlo para que manejen el programa solos...en cambio acá, de un
solo dijeron ”no”. Nuestra ministra en turno les pidió quedarse más tiempo involucrándose en el
trabajo de Chagas.
PR: Pero no...
ER: ”Ya pueden solos”, dijeron.
PR: Ahh ok. Nos parece que El Salvador es el país que tiene más capacidad para detectar
casos...para
(1:13:18)
ER: En recurso humano también. O sea..cuando tengan la posibilidad de ver otros países, no hay
recurso humano institucional (que) un abordaje de la enfermedad como acá. Acá tenemos 7.000.
Ven otras patologías, pero tenemos 7.000 hombres, mujeres también que están trabajando en eso.
PR: Y eso ha sido lo más importante...para ustedes tener esa capacidad de hacerlo ustedes mismos,
no?
ER: Sí sí. Entonces, también nuestro recurso humano que no es operativo, aunque no tenga un
gran...un conocimiento académico muy elevado, pero tiene la capacidad de gestión
comunitaria...pueden gestionar con gobiernos municipales...contrata(r) tan (/contratando) recurso
humano...o sea, en qué apoya el gobierno municipal? Contrata al recurso humano, se involucra en la
parte de educación y promoción...en cualquier situación, pero trabajan. Eso nos ha permitido mucho
ser autosostenibles de a partir del 2010, marzo del 2010 se retira la misión y ya no más.
PR: Pero eso nos parece como buena cosa, no?
ER: Sí!
PR: Que se pueden retirar....[igen snakker lidt i munden på hinanden]
(1:14:53)
ER: Sí, porque nos dejó y caminaba solo, es como un niño....lo sueltas a ver si no se cae...entonces
nosotros nos hemos mantenido en pie...viendo cómo mejoramos eso. Y siempre para mejorar, para
mejorar...lo que ya tenemos. Porque ese es nuestro reto. Y había una experta japonesa, yo creo que
se han dado...haber mencionado que...estuvo con nosotros Emi Sasagawa (?)...ella en Japón...o en
Centroamérica dice ”El Salvador son los mejores”, dice ella, ”quiero ir a algo diferente”...
PR: En un lugar donde se puede mejorar más?
ER: O sea...en Honduras, Nicaragua...lo mismo...en cambio nosotros vamos para....(con ella fue la
última que llegó al programa) en la parte de la JICA. Básicamente eso...hay otra cosa que a ustedes
le interesaría?...estamos a la disposición.
[Igen en periode med lidt ligegyldigt, men igen er der bagefter noget brugbart]
PR: Perfecto. Bueno, más que nada queremos agradecerles su tiempo. Ha sido sumamente
informativo y también quisiéramos saber si hay la posibilidad de visitar a unos centros de salud o
algo así...
ER: Cómo? Cuándo se van ustedes?
PR: Nosotros vamos a quedarnos hasta el 21 de diciembre y el 16 tenemos una cita con la JICA y
pues....
ER: El correo que te mandé, ahí iba el correo de OPS...Victor...
PR: Mejía...pero parece que no funciona porque recibí un correo....
ER: Botado
PR: Y también quisiéramos hablar, si es posible, con unas personas de la universidad o el Sr.
Cedillos.
ER: Bueno, con el Dr. Cedillos, sí....te voy a dar el.....con Victor Mejía...
[Der er lidt mumlen og de skriver noget på en seddel til os]
(1:17:25)
ER: Hemos hecho el tiempo para atenderlos porque lo merecen...
PR: Gracias, gracias...y es otra perspectiva con....hablar con las personas que sólo leyendo....
ER: Nosotros....leo poco. Trabajamos más.
[Igen brugbart]
...ER: Bueno, recientemente...hace un més, nos vino 1.200 (forazgos) de Nifurtimox donado
por...[MG siger noget]...lo chistoso es esto, lo risible de Chagas, del medicamento es que el único
país donde hacen medicamentos es El Salvador...Bayer...
PR: El Nifurtimox?
ER: Sí. Lo hacen acá...de acá Bayer se lo dona a Suiza a OMS. Y de allá viene para Uruguay,
Brasil, Panamá, y El Salvador de regreso [Han griner og skriver imens nogle
kontaktoplysninger]....[han bliver ringet op og tager telefonen og snakker lidt med Victor Mejía fra
PAHO]......
 Vi får Mejías telefonnummer
Jeg spørger ind til om det er muligt at tale med andre fra sistema de salud...og vi laver aftalen om at
få fat på José Luis...og ER siger at hvis vi har brug for at snakke med dem igen, skal vi give besked,
hvis vi har nogle tvivl...derefter ringer han til José Luis og aftaler med ham.
Efter samtalen:
ER siger efter samtalen: OPS compra un bajo de casos
Note: de kører os hjem til hotellet bagefter, da det er på vejen for dem.
Interview with José Luis Rivas Jimenez (= JL in interview), Head of Vectors, Central Region
(operative). 9.12.2015
In the same office as the day before. Dra. Gavidia and Ing. Alfonso González are also present. They
are listening to low radio music, also during the interview.
Note: Often, JL begins a sentence, then changes the subject or wording a bit, so sometimes there are
some ”half” sentences. Sometimes he also answers to something else than we actually thought
about but not very often though.
Before we began to record, the purpose of our thesis was explained, and we asked if it was OK that
we recorded.
... = pause
__= can’t hear what is being said
[ ] = when something is understood but not being said
( ) = If I am guessing a bit about what is being said from the context fx.
PR: First of all, we would like to know a bit about your funtion in the [Chagas] program. We
understand that you are the Head of Vectors in the Central Region.
JL: Yes
PR: Can you explain a bit your daily tasks and how the operative efforts are coordinated in the
Central Region?
JL: Well, as Head of Vectors I see the different diseases. Mostly those that are the biggest problems
currently. Our organization is the surveillance of vector control, the execution and the elaboration of
plans for the control of vectors. And what is related to Chagas...well...each year we prepare
operative plans which are to be executed on a monthly basis. Sometimes we live up to these
because...because of the characteristics of the other diseases...we always have to orientate ourselves
towards those with the highest prevalence at a certain moment, which are currently Dengue and
Chikungunya, and the new disease which is the Zika, you know? So my functions are mostly
orientated towards doing the logistics, the planning of the work so that the different community
units can carry out the activities. And organization, mostly in terms of inputs (/resources)
PR: How long have you been working with the program
JL: With the program? Like?
PR: In your current function.
JL: In my current function – 8 years.
PR: Ok, quite some time. So you also have experience with the collaboration with JICA?
JL: Ahh, yes.
PR: How did JICA participate in the work in the Central Region?
JL: For us it was a very pleasant experience, very good. In fact, we had communities where we did
investigations with the support from JICA, and we worked hand in hand with the collaborators from
Japan who came to support us in the Region. [For example] We had one for ___ months, and in fact
they helped us with: (Kits = equipment – We already know that they helped with equipment so my
guess is that he says ”kits” here – it sounds like that), insecticides, and the community
support...organizing communities and also the initiation of the serological investigation to find the
seroprevalence in some populations. Not in general but specifically in 3 populations in the
Department of La Libertad and 1 in Chalatenango.
PR: How have the transition worked since JICA ended its part of the program?
JL: Well, in reality after that JICA went, we are continuing the activities, working at the municipal
level with the communities more than anything, which is our main focus. In some municipalities
with the support of the mayors’ offices (Alcaldías) and the health promoters who are responsable
for doing the vector surveillance, mostly in the rural areas. The serology have still remained a bit (in
the background)...because we have to continue with the attack phase against the vector, and then
possibly continue with the serology.
PR: You mentioned that you for example collaborate with the mayor’s offices, and in our meeting
yesterday [with Ing. Romero and Dra. Gavidia] we became aware that the program collaborates
with actors who are not part of the health system, like the mayors’ offices, the municipal
governments, and the schools. And in your opinion, what are the benefits of collaborating with
actors who are not part of the health system?
JL: For us as an institution, it is very important becacuse the communities have other opportunities
than other actors to contribute to control the risk, more than anything the vectorial [risk]. The fact
that as an institution, we do not have the capacity to operate and cover a bigger range of action...for
example in the spraying, if the communities, the mayor’s offices, and the NGOs did not help us...as
a region we only have a certain amount of resources for the spraying, and that is the activity which
we on: vector control and breaking the chain of transmission. It is in this regard...that the support
from the mayor’s offices and the communities help us the most to avoid that the disease continues
to____(I think that he says something about avoiding that the disase becomes more widespread) but
yes: it is of great relevance to have the support from the NGOs and the mayor’s offices.
PR: Which NGOs are those?
JL: For example PLAN [Internacional, I think: he mentions that one later], there is the (ProcSal?
Cannot hear exactly) – a Spanish corporation which helped in the serology in San Pablo Tacachico.
They made about 900 tests, and of those ___percent had the parasite. It is a great help because
[serology] incur high costs to carry out.
PR: And do you also cooperate with other organizations from here from civil society, such as
religious organizations or other community organization?
JL: In reality, it is mostly NGOs. With regards to religious organizations, the involvement of those
is minimal because they (work with) other types of diseases. Yes, some are present in some
communities but not related to Chagas disease...Well, at least in our region we do not have a
religious group which is supporting [the work with Chagas] currently even though we always
consider that they are a group that can be fundamental in the struggle...in the elimination of Chagas.
PR: Very well. Who are carrying out the management and analysis of data currently in your region?
JL: In reality, it is the the SIBASIs and of course the Region that are...the units gather the
information. But mostly it is the....activities of surveillance and [spraying of] housings – this
information goes into the system because it is a system...where you are seeing the housings that
have been inspected for Chagas and the housings that have been sprayed also. We are registering as
community units, as SIBASI, and as Region [Meaning: they are all registering their actions, I guess]
PR: We have become aware that a principal part of JICA’s work was to strengthen the
communication between the municipal, regional, and central levels. In your opinion, how was the
communication strengthened in the Central Region?
JL: Well...we created connections through the directors of the community units and the health
promoters. They always visit the mayor’s offices. In fact, for all the diseases a local management is
made which is the primary actor and responsible for the health in the municipalities. Afterwards,
this information is always registered by us as an institution___and a report (is made) through the
community units and the SIBASIs.
PR: And this type of communication can also be used for other health issues than Chagas, in your
opinion?
JL: In reality, yes. Our channels of communication are very efficient because there is a system of
civil protection at the level of regions, nationally, departmentally, and communally. So the
information always arrives at the health units (=health centers). Afterwards it (reaches) the
communities so that they can understand it [the information] on time [maybe in time to administer
the proper treatment but he doesn’t say]. Sometimes it is not achieved because it is a rather complex
system but in the majority of cases it does not take more than 24 to 48 hours before the information
is there...now with telephone...almost everyone at the rural level has a telephone [I think that he
means the rural health centers]. It is rare that the information does not arrive [at the health centers]
because the information is not only sent with papers but it is sent by phone...and when there is a
community assembly where they carry out...monthly the health promoters and the directors have a
meeting and there they touch on the themes of all the diseases with the highest prevalence.
PR: Now we also have a few questions about the spraying, the community surveillance, and the
community participation. In our conversation yesterday, we became aware that the voluntaries of
the communities also should get involved in the spraying, and in your opinion, to which degree do
the become capable of using the equipment and of carrying out the spraying in the different
municipalities?
JL: That depends on the communities because there are communities at risk, communities which
still are___in those we can infer and do...achieve to build the capacities so that they get the
knowledge needed for working and applying the spraying techniques correctly. We use the
organization which the health promoters have. We convoke them to a meeting often, and there we
explain the sprayings which have to be carried out to be able to eliminate the disease. But before
that we build their capacities with regards to the use of the insecticides, the risks if they are not used
adequately, the clothing which has to be used by the person [carrying out the spraying] in the house.
We mostly do these [capacity buildings] in the rural areas because that is where the people have
their own equipment which they use to do the work. So with this [approach] we are teaching them
so that they work. The truth is that it is rather difficult to monitor this because of the fact that we do
not have the sufficient time. If it were just the program [the Chagas program, I guess], it could
assure that we were there at the best time...it is subjective to say that it works a 100% (I think that it
means that it would not be objective to say that it works 100 %)
PR: When is it possible to do the evaluations, which indicators are used?
JL: We...before the spraying we carry out the entomological investigations, and we have the ranges
that from 5 percent and below [infestation rate] is low risk. Between 5 and 100 % is high risk. We
mostly focus on the high risk communities, which are the zones that we work with. We already
have structured the form of typification and evaluation of the communities, So after the first
spraying, we have to do an evaluation after 6 months to see if 100 % of the triatomines died in that
zone. Upon the activities that we are going to continue with depend on the finding of the positivity
[the infestation rate in the follow up]. If 5% is still not reached, it is necessary to spray once more.
And it is three times that it is [sometimes] necessary to spray and evaluate to see if it has been
effective.
PR: Is the equipment always available or is there sometimes scarcity, because yesterday we were
told that there has been scarcity of equipment before.
JL: Currently we have the equipment that we are working with. Yes, sometimes there are problems
with spare parts because often we are on the road and____but for the ones that we have, we have
the spare parts...
PR: Apart from the spraying, the communities should also do the passive surveillance..
JL: Exactly. The passive surveillance...it is always the recommendation that we make in all the
communities because the active [surveillance] is when we go to the communities and we do it, and
we convoke the communities, and we do a determined date. But we inform everyone that they are
coresponsible: With their family, with their children, with their neighbours, with their community of
doing the passive surveillance. That each triatomine that they find in their houses – they should
send it to the promoter, who in turn___ afterwards (ends up) at the SIBASI. Often to be examined
by an entomologist...because we also evaluate the natural parasitic rate of the triatomine [= how
many of the triatomines have the parasite]
PR: Does it vary, how much the different communities participate in this surveillance?
JL: Yes. Some of them consider the disease rather important, and others listen but do not attend to
the call [for action]. It also depends on the conditions of the communities, and some of them say
”no, the disease does not cause any harm...I have been having chinches in the house for a long time”
and others say ”No, it is better that I kill them because it is expensive to send them to the promoter”
or: ”it died and was destroyed when I captured it, and now I cannot send it”. So all these
circumstances...What happens is that sometimes the installed capacity to be able to___the structure
of triatomines is difficult [I think that it means that they do not always have the capacity to storage
all the triatomines]. There are some places...where they have found up to 400 triatomines in a single
house. But it is recommended that they only send 2 or 3 species to verify but the communities are
not always sending them.
PR: In your opinion, how can this situation be improved – Is it possible or are there other challenges
of the communities that are more important to them?
JL: Yes, in reality it is...[how to improve:] promoting a bit more, to be more extensive, more
promotional about what the disease is so that they know how important it is to maintain the house
free of the vector. As long as they do not understand, they are not comprehending the degree of risk
that it means for them and for their families, they are not going to have the degree of conscience to
be able to eliminate [the vector, risk]. In reality, what they are told is to eliminate it...no to send a
100% of them [chinches]. But yes, the surveillance is important because in this way we become
aware that there is still a parasitic circulation in persons and in the species.
PR: Yesterday, Ing. Romero and Dr. Gavidia informed us that the Chagas program make
recommendations to the communities about housing improvements, such as filling cracks [in the
walls], changing the roofs, and according to your experience: To what degree are the communities
able to follow these recommendations?
JL: As I told you, if the people committed themselves, this could do...that they do it as something a
bit more practical; that they would not need to spray, or collect triatomines in order to have the
house free from the vector. It is very difficult, I tell you, because of the economic conditions that
the population has because if we go to a house with mud walls, the filling of cracks is not possible
because it cracks again constantly. But yes it is promoted constantly by the institution: we promote
it in the mayors’ offices, we promote it in the communities that they are always filling the cracks,
because the vector dies from a lack of oxygene...they can go up to 10 days without oxygene but
after some time they will not be able to find a single hole to breathe. But yes, it is promoted a lot
that they do a roughcast of the houses in the communities where it is feasible. Because we have
experienced ___the material [maybe lacking the material]...often there are situations where it is not
possible for us to promote the housing improvements. Earlier there was the support from the PLAN
Internacional, the Plan Padrino...that were supporting the poor communities. They gave the
material, and they began to replace the houses made with adobe, mud, or tree with mixed
material...which permitted better living conditions. But yes, the population...with [general?]
improvements, the housing aspect can improve.
PR: But the PLAN ended?
JL: Plan Internacional retired from that area, but they are currently engaged in childhood support,
but not diseases...housing improvements is not their priority because the resources ran out, now they
are not in the aspect of construction.
PR: Is there sometimes also scarcity of resources for the carrying out of your activities, or are there
always resources to carry out...
JL: What is related to activities...human resources are limited...we are not going to cover that up.
We cannot say: ”We are going to spray 10.000 houses this year” if we do not have the
resources...because of the fact that___[and we cannot] say: ”We will take this community, and we
are going to contribute to the roughcast, the housing improvements” because we, as institution, do
not have the resources for that. The Ministry of Housing has the responsibility of improving the
houses. But we always have the resources for the sprayings. As institution the support is always...a
considerable amount is budgetted each year, for each fiscal period, and there the annual plans are
included in which the attention to (in)transmissible diseases is included.
PR: In the last few years, have there been any changes in the inputs for the project, or have they
remained the same?
JL: During the last 2 years, yes we have started to have a new insecticide...of liquid base but we
have worked with a powder based one [before?]...now we are working with liquid...we are testing
which one is of better quality for the elimination....but yes...the one which we have used has been
functional so far.
PR: We would also like to know a bit about the strategy of information, education, and
communication. And in your region, what are the activities that are being carried out as a part of
this strategy currently?
JL: We have an integrated plan of promotion...education...in which Dengue, Chagas, Malaria,
Rabies...and also the diseases...Zika and Chikungunya are included. So all that...we are constantly
working with all these. Sometimes we are invited to local and regional radios, and there we often
talk about the disease. There is a special national day [Chagas day]...It is not only that day, but the
whole month. Sometimes we use the whole month...to promote the disease. And the in the plan of
work...at least once a week a small talk is to be given about the disease.
PR: And in your opinion, does this strategy have a big impact. Or is the theme of Chagas more
well-known now?
JL: Yes, the people are more conscious. They know that the disease exists; what it is that they have
to do to eliminate the vector, and the risks of the disease...they are eliminating in the communities.
PR: And it was not like that 10 years ago?
JL: In reality, no. It was not that relevant...It was not part of the activities...much relevance was not
given [to the theme]...the term ”neglected disease”, it is used a lot, right?...[Chagas] It was
neglected, and it was not sufficiently considered important until people started to realize that the
indicators were at almost the same level as HIV...they began to make considerations and to promote
it a bit more. In fact____there is a new strategy which includes all the diseases in order to
work...and in the annual plans we also have a specific part for Chagas disease.
PR: We learned yesterday in our meeting that all the acute cases of Chagas should be treated with
Nifurtimox. Who administers the medicine in the Central Region?
JL: The hospital. Previously, we had a relation with the hospital and we referred the cases. Or...all
the investigated cases in the age of being able to___medicine. They are always given it but firstly
they are referred because there they do the whole examination, there, there is an infestologist, there
is a cardiologist. So while not everyone are____even though it has been detected that it is the
disease, you cannot give them the medicine because the medicine has to be quite controlled because
the hospital follow the behaviour [of the patient] as long as they take the medicine, and later there
are some tests...
PR: Yesterday, we also talked about that the way of finding the acute cases is to look at the eyes
[swelling], to look for the Chagoma. But as Chagas is sometimes asymptomatic, are there
sometimes problems related to finding all the cases?
JL: Yes, really. Some remain...are not detected in time because...if it is a child___that the child was
with the symptoms in time, the child was not brought to a doctor. So it depends a lot on the
knowledge of the parents. Now, there are many that remain...because when we come to see them,
the symptoms are gone, and that is the risk. But the majority of the cases are detected because we
have health promoters in the majority of the communities, and they know which of the symptoms
are the most visible in the acute phase. Because if we do not detect it in the acute phase, well, it is
very difficult to control it. I think that there is [now?] a bit more...knowledge in order to detect an
acute case in time. However, we had a case which the doctors had not detected , and out colleague
from Malaria, from Vectors [the Vector unit] discovered it, he saw it, and asked the girl ”how long
has your eye been like that?”, and it was already 22 days. The [swelling of the] eye was already
smaller...As I imagine that Dr. [Gavidia] mentioned, it is not a 100 %...it is like 25 % of the cases
that have that Romaña’s sign. It is not a 100% of the cases who develop it. Now, the Chagoma, yes.
Where the Chinche (made the bite), will always be red but not all the cases have the Romaña’s
sign...and the others which do not present the symptoms like the high fever...
PR: Are there also initiatives which come from the communities...Or that the members of the
communities make their own initiatives and suggestions for the program. Or does everything rather
comes from the program?
[Telefon rings - Dra. Gavidia’s]
JL: In reality, everything comes by way of us as the vector program[everything comes from them].
The communities have today begun to solicit or to suggest some solutions to their necessities. But it
is rather difficult because they are more focused on...infrastructure improvements in the community,
such as a road or a communal house. So those are more relevant things for them. In the case of
Dengue, yes, there are some who are working...It happens rarely that a community says ”we are
going to spray our houses” [for Chagas]. For example, where we did the serological investigation in
San Pablo Tacachico, there yes, the community said ”we are going to spray”. They called us and
said ”On that date we are going to spray, we are going to fumigate to eliminate the chinche”. But
that is not...it is a minimal quantity of communities that solicit support [for Chagas]. Mostly the
focus is on the fumigation related to Dengue.
There are also campaigns of house cleaning in the communities____and they solicit the
support...there are communities that are organized and others that are not...for example in
Chalatenango...There are three communities that are organized...there is a lot...work of basic
sanitation...but the spraying...that was in Tacachico where the community said ”we are going to
spray”, and they turned to the promoter or the director of sanitation or the health unit so that they
could manage the inputs, and they [community members] could work.
PR: Yesterday, we also talked a bit about the reform of the health system in 2009, and in your
opinion, has the attitude of the communities changed? Or...with the Integrated Health Service
Delivery Networks – is it easier for the communities to be attended to?
JL: Yes yes, because apart from the rise in the number of community units, there are more
promoters, there are more resources. So it means that for every 350 persons, for every 300 persons,
there are certain resources that are going to be given. Not the total service but yes, the most
(important) necessities [in the communities] at the moment are going to be detected, and the tie or
the chain of service is created so that the necessary (treatment) can be given at the hospital at the
third level [of service]
PR: Perfect, and that means that the people have more possibilities of being attended to?
JL: Exactly
PR: But do the people actually also use these possibilities of being attended to, or don’t they know
about them?
JL: In reality, they do use them. Because they are always consulting, they are always making
questions. Even though, in our communities, the men often do not consult...for a fever they are not
always going to consult. Sometimes they wait until it passes...sometimes we [El Salvadorians]
sometimes self medicate...we do not believe in doctors [laughs]...we are going to buy an
Acetaminophen [medicine that is close to Paracetamol]...”with this I am going to get well”...but we
are not very quick at demanding the service [from doctors etc.].
PR: Ok. The serological studies concerning children under 15. Are they still being carried out?
JL: That was really considered a bit____pilot [pilot part of the program]. Now it is not being done.
Unless if it would be a house where a [sero]positive chinche was found. In that case, yes it will be
referred. But this family [in that house] _____ if there are two children, and the father was
bitten...and chronic Chagas was discovered, the children will be sent [to serology]. But it depends
on the input that would be in the laboratory to carry out the tests...(I imagine) that Ing. Romero
mentioned that ___ sometimes the providers of the tests are not at hand [available] in time, you
know? The other thing is that it has a rather elevated cost...we cannot say ”in this community, we
are going to test a 100%” we know that it is a lot of resources. Even though...if we had this [the
resources], we could do it, but it is rather complicated.
PR: And the resources for these tests. Do the come from outside or from the Ministry of Health, or
from PAHO?
JL: Normally, the studies have been carried out with the help of JICA and PAHO. Because the
Ministry (focus on) working with the cases that are...already positive or chronic, or when there is a
[sero]positive chinche.
PR: Finally, we would like to know a bit about your opinion on what have been the biggest benefits
of the Chagas program since its beginning in 2003 until now, and also for the future?
JL: Well, the benefits are...having a system that helps us to pick up [=discover] the cases more
easily. The benefits...because we can transcend...not only apply insecticides, but the persons can
find [use] different ways of avoiding the vector. For example, a clean house. It is not necessarily to
have a big and well-constructed ___ but rather to maintain a clean house is an attitude that I [not
talking about himself but people in general] can use daily to eliminate [the vector], and take all the
household effects that I have out of the house to avoid that the vector lives with us1. And the other
thing is that in the majority of cases all the doctors...be it from the system or __ from the social
1
Because the triatomine often hides under belongings if a house is a mess. So to take them out for a while enables to
find the bugs.
year2 are qualified to detect the cases in the best way. Also the authorities...at the superior level are
aware that the disease exists and that it is necessary to keep working. And in reality, the personnel
at the other levels __ like health promoters, inspectors, they now have the conscience that the
disease exists.
PR: And the Chagas program, has it also strengthened the health system generally, in areas that are
not related to Chagas, in your opinion?
JL: Yes, it has been strengthened. For example, the vector unit is now part of the environmental
sanitation unit. The vector unit did not have...let us say, the attention that it has now
because...environmental sanitation generates some funds. So with these funds it is possible to
palliate some necessities.
PR: And in this way the approach for all the vectorized diseases has been strengthened?
JL: Exactly, because today we have at our disposal...a single/sole information system is used, which
is not for a 100 % of all diseases but for example, what is of major relevance...Dengue, every year it
takes up more time...it takes 80 % of all the time, the activities. For this there is a system, so that
every single piece of information, every single activity that has been carried out, a case which you
look for, can be found at this very moment in the system. The same with Chagas. If there is a
chronic case or if tests have not been carried out, it would appear in the system that the tests are
lacking or that [the patient] has not received medicine or follow-up, and that enables us to...not rely
on a large quantity of documents and papers in order to look for a case, we just go to the system and
there we see if the follow-up has been done.
PR: We would also like to know a bit about the challenges of the program, and in your opinion,
what are the major challenges now for the prevention of Chagas?
JL: The major challenge would be to cut the disease with a single strike. As it is gradual/phased,
this cannot be achieved until the homes are improved. That would be the biggest challenge in order
to cut the chain of transmission, it would be necessary to change the social aspect of the
communities at the highest risk...Let us say that they are at indicators...from 10 to 20 percent and
above [probably infestation rate] that are...and the other thing is to be able to do the serology. Not
only when there are cases, but to take a percentage of the population into consideration, let us say in
2
Kind of internship that the doctors have to do as a part of their education, often in a rural area. José Luis explained
this on our field trip.
the communities at risk – rural more than anything, where the entomological indicators [of
infestation] are present. That would be a rather big challenge, because it would permit us to
say...well the ideal would be no cases, right? And even though no cases would be found, I could say
”These communities are free of the parasite”. Because often, a 100% of the logistics needed to
arrive in time to control a case is not at disposal...and as the vector lives for two years, it gives us
some time to cut the chain. But too late __ . However, as we see...carrying out serology and
spraying...seeing that the things are going ____ (in the right direction). = (I think that it means that
when they do both the spraying and the serology, they can see if things go in the right direction).
PR: Finally, we would just like to know if there is something about which we have not asked, in
your opinion, or if there is something that you would like to add?
JL: Well...no. I think that everything is fine.
After the interview but also recorded: We asked if it would be possible to make a visit to a
SIBASI and a health center, and JL says that it probably is. Here Dr. Gavidia was a very big help in
setting up the trip and in making the plans to go a few days later.
Entrevista con José Luis Rivas Jimenez, Jefe de Vectores, Región Central (operativo).
9.12.2015 På kontoret. Dra. Gavidia og Ing. Alfonso González også til stede. Gavidia hører lav
radiomusik.
(Først introduktion inden optagelsen, hvor vi også spørger om det er ok, at vi optager osv.)
(0.16) PR: En primer lugar quisiéramos saber un poco sobre su función en el programa.
Entendemos que usted es el Jefe de Vectores en la Región Central.
JLRJ: Sí
PR: Cierto?
JLRJ: sí
PR: Puede explicar un poco sus tareas diarias y cómo se coordinan los esfuerzos operativos en la
Región Central?
JL: Bien, como Jefe de Vectores, veo las diferentes enfermedades – más que todo las que están (de/
el) mayores problemas en este momento. Nuestra organización es la vigilancia de control vectorial,
la ejecución y la formación de planes para control de vectores. Y lo que relaciona a
Chagas..pues..año con año nosotros preparamos programaciónes operativas para ser ejecutadas mes
por mes. Algunas veces cumplimos por consecuencia de que...por la cara que tienen las otras
enfermedades que siempre tenemos que orientarnos más a las que están en el momento con mayor
prevalencia como son en este momento Dengue y Chikungunya y la nueva enfermedad que es el
Zika, verdad?
Entonces mis funciones (están) más que todo orientadas a hacer la logística, la planeación
(planning) del trabajo para que las diferentes unidades comunitarias realicen las (actividades),
Y organización – más que todo la gestión cuando se...(=atribuyen?) insumos.
PR: Cuántos años lleva con el programa?
JL: Con el programa como?
PR: En su función ahora?
JL: (en) Mis funciones llevo 8 años.
PR: Basante tiempo. Y entonces también tiene usted experiencia con la colaboración con la JICA
(1.59) JL: Ahh, sí.
PR: Cómo participó la JICA en el trabajo en la Región Central?
JL: Para nosotros fue una experiencia muy grata, muy buena. De hecho tuvimos comunidades
donde hicimos investigaciones con el apoyo de la JICA y trabajamos de la mano con los
colaboradores también de Japón que venía a apoyarnos en la región. Tuvimos uno por (cuatro?)
meses y de hecho nos apoyaron con lo que era: aparte de (KITs?), insecticidas, y el apoyo
comunitario...organizando comunidades y también levantamiento de la encuesta serológica para ver
la seroprevalencia en algunas poblaciones. No en general, pero en específico en 3 poblaciones del
departamento de La Libertad y 1 en Chalatenango.
PR: Cómo ha funcionado la transición desde que la JICA terminó su parte del programa?
JL: Pues, en realidad después de que la JICA se va, nosotros continuamos con las acciones,
trabajando al nivel de municipios con las comunidades más que todo... donde nos enfocamos más,
en algunos municipios con el apoyo de las alcaldías y los promotores de salud que son los
responsables en el área más que todo rural para hacer lo que es la vigilancia del control vectorial.
No así...la serología se ha quedado un poco en____porque todavía tenemos que continuar con el
fase de ataque al vector, para continuar posiblemente con lo que es la serología
PR: Mencionó que colaboran por ejemplo con las alcaldías y en nuestra reunión ayer nos enteramos
de que el programa colabora con actores que no pertenecen al sistema de salud. Como las alcaldías,
los gobiernos municipales y los centros educativos, y en su opinión cuáles son los beneficios de
colaborar con los actores que no pertenecen al sistema de salud?
JL: Para nosotros como institución, es bien importante porque las comunidades tienen otras
oportunidades de que otro actor contribuye a controlar lo que es el riesgo, más que todo el vectorial.
El hecho de que como institución no tenemos la capacidad para poder operar y abarcar un mayor
rango de acción. Por ejemplo en el rociado si no (tanto) las comunidades, las alcaldías y las ONG
nos ayudarían mucho...como región solamente contamos con tantos recursos para el rociado y es la
acción que nosotros enfocamos para hacer control vectorial y cortar la cadena de transmisión. Es
ahí en punto... el apoyo de las alcaldías y de las comunidades que más nos ayudan a evitar que la
enfermedad siga____pero sí: de gran relevancia tener el apoyo de las ONGs y las alcaldías.
PR: Cuáles ONGs son?
JL: Por ejemplo PLAN (?)..nosotros tenemos y (B)Roczal (?) una corporación española que____la
serología en San Pablo Tacachico. Sacaron unas novecientos muestras____un por ciento con el
parásito____Es un gran ayuda porque son altos costos que (incurren?) para poder hacer.
PR: Y también colabora con otras organizaciones de acá de la sociedad civil como organizaciones
religiosas u otras organizaciones de la comunidad.
JL: En realidad: más que todo son las ONGs. Lo que es las organizaciones religiosas es (bien
mínima el involucramiento de ellos porque (van/trabajan) en otro tipo de enfermedad. Sí, están
presentes en algunas comunidades, pero no es en lo que es la enfermedad de Chagas...bueno por lo
menos en nuestra región no tenemos en este momento un grupo religioso que esté apoyando aunque
siempre consideramos que son un grupo que puede ser fundamental en la lucha....en la eliminación
del Chagas.
PR: Bueno. Ahora, en su región quiénes realizan el manejo y análisis de datos?
(6:28) JL: En realidad son los SIBASI y por supuesto la región (que son).... las unidades recolectan
la información. Pero más que todo lo que es...acciones de vigilancia y vivienda - esa información
entra al sistema porque es un sistema..donde se va viendo las viviendas inspeccionadas por Chagas,
y las viviendas rociadas también nosotros vamos registrando como unidades comunitarias, como
SIBASI y como Región.
PR: Nos hemos enterado de que una parte principal del trabajo de la JICA era fortalecer la
comunicación entre los niveles municipales, regionales y centrales, y en su opinión cómo se
fortaleció la comunicación en la Región Central?
(7:20) JL: Bien nosotros...creamos vínculos a través de los directores de las unidades comunitarias y
los promotores de salud. Ellos siempre van a las alcaldías. De hecho para todas la enfermedades se
hace una gestión local que es el primer actor y el responsable de la salud en los municipios. Luego,
esta información siempre nosotros como institución la registramos____y comunicado__ un informe
que va a través de las unidades comunitarias, los SIBASI.
PR: Y también se puede utilizar esa forma de comunicación para otros temas de salud que el
Chagas en su opinión?
(8:05) JL: En realidad sí. Los canales de comunicación en nosotros es bien eficiente porque se
cuenta con un sistema de protección civil al nivel de regiones, aquí nacional, departamental y
comunitaria. Entonces la información llega siempre a las unidades de salud. Luego es (distribuida?/
) hacia las comunidades para que estos puedan entenderla a tiempo. muchas veces no se logra...
porque hay un sistema bastante complejo, pero en la mayoria de los casos no tarda entre el 24-48
horas y está la información....Ahora con teléfono, casi todo el mundo al nivel rural cuenta con un
teléfono...es raro el lugar donde no se llega porque la información no va solamente a través de un
papel, sino que va a través de un teléfono..y ese cuando hay asamblea comunitaria y donde se
realizan lo que es...mensualmente los promotores de salud o los directores tienen una reunión y ahí
tocan los temas de todas las enfermedades de mayor prevalencia.
PR: Ahora también tenemos unas preguntas sobre el rociado, la vigilancia comunitaria y la
participación de las comunidades.
En nuestra conversación ayer, nos enteramos de que los voluntarios de las comunidades también
deben involucrarse en el rociado y en su opinión en qué grado se hacen capaces de utilizar los
equipos y realizar el rociado bien en los diferentes municipios?
(9:49)
JL: Eso dependerá de las comunidades porque hay comunidades de riesgo, comunidades que
todavía son____en estos nosotros sí podemos inferir y hace...lograr capacitar que ellos se queden
con el conocimiento para poder trabajar y aplicar correctamente las técnicas del rociado. Nosotros
utilizamos la organización que tienen los promotores de salud. Los convocamos muchas veces a una
reunión y ahí explicamos cuáles son los rociados que hay que hacer para poder eliminar la
enfermedad. Pero previa a estos se les capacita sobre lo que es el uso de las insecticidas, los riesgos
que se corren cuando no son usado y utilizado adecuadamente; la vestimenta que tiene que utilizar
la persona en la casa...los hacemos más que todo en los áreas rurales porque son donde la gente
cuenta con muchas veces con su equipo propio que utilizan para trabajar. Entonces con eso nosotros
les vamos enseñando para que___trabajando. La verdad es: monitorear eso es bastante difícil por el
hecho de que no contamos con el tiempo suficiente para darles una___si fuera sólo el programa
podría asegurar estamos en un momento bien óptimo...es subjetivo decir que eso funcionará un cien
por ciento.
PR: Cuándo es posible hacer esas evaluaciones, cuáles indicadores se utilizan?
(11:24)
JL: Nosotros..después de........previa al rociado levantamos las encuestas entomológicas y tenemos
los rangos de que: el 5 por ciento para abajo es bajo riesgo. Del 5 por ciento hasta el 100 por ciento
es alto riesgo. Nos enfocamos más que todo en las comunidades con alto riesgo y con esas son las
zonas con las que trabajamos. Tenemos ya estructurada la forma de (tipificación) y de evaluación de
las comunidades. Entonces después del primer rociado, nosotros tendríamos que hacer una
evaluación a los 6 meses para ver si se murió el 100 por ciento de los triatominos en esa zona. De
encontrar esa positividad dependiendo__la actividad que vamos a seguir. Si no alcanza todavía el 5
por ciento, hay que volver a rociar. Y son tres veces que hay que rociar y evaluar para ver si eso
está teniendo efictividad.
PR: Siempre están disponibles los equipos o a veces hay escasez porque ayer nos contaron que
antes ha habido un poco de escasez de los equipos.
(12:36)
JL: En este momento tenemos equipos con los que estamos trabajando. Sí, a veces hay problemas
con repuestos porque muchas veces vamos en el camino se va______todo interno pero
tenemos...con los que tenemos podemos dar repuesto____los que estamos programando..y las
comunidades que tienen el apoyo para poder trabajar.
PR: Aparte del rociado, las comunidades deben realizar la vigilancia pasiva
(13:10)
JL: Así es. La vigilancia pasiva..siempre es la recomendación que nosotros estamos haciendo en
todas las comunidades porque la [vigilancia] activa es cuando nosotros vamos a las comunidades y
lo hacemos, y le convocamos a la comunidad en grupo (ordner flere huse på en gang fx?) y
hacemos una fecha determinada, pero cada quien se le hace saber que es coresponsable. Con su
familia, con sus hijos, con su vecino, con su comunidad de hacer la vigilancia pasiva. Que cualquier
triatomina que encuentren en su vivienda – ellos deberán de enviarlo al promotor y éste a su
vez___y posteriormente al SIBASI. Muchas veces para ser examinado por entomologo...porque
también evaluamos el índice (parasiteña) natural del triatomino
PR: Varia mucho cuánto las diferentes comunidades participan en esa vigilancia?
(14:08)
JL: realmente sí. Unas que consideran bastante importante la enfermedad, y otras que escuchan pero
no atienden mucho al llamado. También depende de las condiciones de las comunidades que ellos
dicen ”no la enfermedad___no causa daño...mucho tiempo que yo tengo chinches en la casa...” y
otros que dicen ”no, mejor yo los mato porque le cuesta mucho enviarlo al promotor” o ”me murió
cuando lo capturé (blev ødelagt) y ya no puedo enviarla”.
Entonces todas esas circunstancias....lo que pasa es que a veces la capacidad instalada para poder
___estructura de triatominos es bien difícil. Hay algunos lugares que tienen hasta...se han
encontrado hasta 400 chinches en una sola vivienda. Pero se recomienda que solamente se manden
dos, tres espécimenes para verificar el (rastro), pero no siempre las comunidades están enviandolos.
PR: En su opinión, cómo se puede mejorar esa situación – es posible o hay algunos otros desafíos
de las comunidades que son más importantes para ellos?
(15:28)
JL: Sí, en realidad es... como promover un poco más, sea más excesivo, más promocionales en lo
que es la enfermedad para que ellos sepan cuán importancia es mantener libre una casa del vector.
Porque mientras ellos no entiendan, no comprendan el grado de riesgo que comprende la
enfermedad para ellos y para su familia, no van a tomar el grado de conciencia que tienen para
poder estar eliminando. Realmente lo que se le dice es que la elimine...no que los envie el 100 por
ciento. Pero sí, la vigilancia es importante porque de esa manera nosotros nos damos cuenta que
todavía hay circulación parasitaria en las personas que conviven y en los espécimenes.
PR: Ayer, el Ing. Romero y la Dra. Gavidia nos informaron de que el programa de Chagas hace
recomendaciones para las comunidades sobre mejoramientos de las viviendas, como rellenar
grietas, o cambiar el techo y según su experiencia: en qué grado pueden seguir esas
recomendaciones las comunidades?
(16:45)
JL: Como le digo, si la gente se comprometiera esto podría hacer.... que ellos lo haga como algo
más práctico, que ya no necesitarían rociar, ni estar recolectando triatominos para poder tener libre
del vector. Es bien difícil, le digo, por las condiciones económicas que la población tiene porque si
vamos a una casa de bajareque no permite muchas veces el repello porque este se revienta
(=reventar) constantemente. pero sí se promueve constantemente como institución: lo promovemos
en la alcaldía, lo promovemos en la comunidad para que ellos constantemente estén sellando
grietas, porque al faltar oxígeno al vector este muere ...ellos pueden ir hasta unos 10 días sin
oxígeno, pero transcuridos tiempos no va a encontrar una sola salida para poder respirar. Pero sí, se
promueve mucho que se haga el repellado de las viviendas en aquellas comunidades donde sí es
factible...porque nos hemos enfrentado con____el material..muchas veces son situaciones de que no
están al alcance de nosotros promover que una comunidad haga lo que es el mejoramiento de la
vivienda. Antes se contaba con el apoyo de PLAN (?) Internacional, Plan Padrino...que iban
apoyando con las comunidades pobres. Ellos daban el material y se empezaba a cambiar lo que era
la casa de adobe o bajareque o madera por una casa del mixta(?)...que les permitía mejores
condiciones de vida. Pero sí, la población...como está mejorando, va cambiando el aspecto de la
vivienda.
PR: Pero ese plan se acabó?
JL: Plan Internacional se retiró con lo que era el apoyo en esa área, pero sí ellos cuentan ahora con
un apoyo a la niñez, pero no de enfermedades....mejora de viviendas no es para ellos la prioridad
porque todo se va acabando los recursos...ya no están en el aspecto de la construcción.
PR: también hay a veces escasez de recursos en la realización de sus actividades o siempre hay
recursos para realizar...
(19:15)
JL: En lo que se refiere a las acciones....recursos humanos es limitado...eso no lo vamos a tapar. No
podemos decir: ”vamos a rociar 10.000 viviendas en este año” si no contamos con recursos por el
hecho de que______(de kan ikke...:) o decir: ”tomamos esa comunidad, y vamos a contribuir a
hacer el repello, el mejoramiento de las viviendas” porque nosotros como institución no contamos
con recursos para ello. El Ministerio de Vivienda ese tendría que estar responsables de mejorar
viviendas. Pero recursos para hacer los rociados siempre tenemos. Como institución el apoyo
siempre tiene, se presupuesta una cantidad considerable para cada año, para cada periodo fiscal y
ahí van incluidas lo que es las programaciones anuales en lo que es la atención a las enfermedades
transmisibles.
PR: Pero en los últimos años, ha habido cambios en los insumos para el proyecto o siguen los
mismos más o menos
(20:24)
JL: durante los últimos 2 años, sí estamos contando con...nuevo insecticida..de base líquido, pero
trabajamos con polvo metable (antes?)...ahora estamos trabajando con líquido...se está viendo qué
funciona lo mejor la calidad de eliminación....pero sí...lo que hemos tenido ha sido funcional hasta
ahora..
PR: También quisiéramos saber un poco sobre la estrategia de información, educación y
comunicación. Y ahora en su región, cuáles son las actividades que se realizan en esta estrategia.
JL: Nosotros (pedimos?) un plan integrado de promoción, educación donde tienen que incluirse
Dengue, Chagas, Malaria, Rabia....más que todo las enfermedades que están...zika y la
chikungunya. Entonces todo eso...constantemente estamos trabajando con ellos. A veces nos invitan
a radios locales, radios regionales y ahí aprovechamos muchas veces para hablar sobre la
enfermedad. Se cuenta con un día nacional en especial...no sólo es ese día, sino que es todo el mes,
algunas veces tomamos todo el mes...para promover la enfermedad. Y en el plan de trabajo por lo
menos debe de darse un charla a la semana promoviendo la enfermedad.
PR: Y en su opinión tiene un gran impacto esa estrategia. O sea está más conocido el tema de
Chagas
(22:17)
JL: Sí, la gente ya tiene más conciencia. Sabe que la enfermedad existe, qué es lo que hay que hacer
para eliminar el vector y los riesgos para la enfermedad....se va eliminando en las comunidades
PR: Y no era así hace 10 años
JL: Realmente no. No era tan relevante para....no estaba dentro de las actividades...no se daba
mucha relevancia porque....el término enfermedad ”desatendida” lo dicen mucho no...estaba
desatendida y no se daba importancia suficiente hasta que se empezó a ver de que los indicadores
eran casi al mismo nivel del VIH...empezaron a tomarse consideraciones y a promoverlo un poco
más.
De hecho siempre se está trabajando con (las fichas?)...hay una nueva estrategia que incluye todas
las enfermedades para poder trabajar y en las programaciones anuales también nosotros también
tenemos una parte___ para la enfermedad de Chagas.
PR: Ayer entendimos en nuestra reunión que todos los casos agudos de Chagas deben ser tratados
con el Nifurtimox: quién administra la medicina en la región central?
(23:29)
JL: El hospital. Anteriormente, nosotros siempre teníamos una relación con el hospital y referíamos
los casos. O sea todos los casos investigados que están en la edad de poder _ medicamento..siempre
se le da, pero son referidos primero [ahora??] porque allí se hacen todo el examen allí hay
infestologo, hay cardiologo. Entonces mientras no pasen todos_____aunque ya se ha detectado que
es la enfermedad, no puede darse el medicamento porque tiene que ser bien controlado el
medicamento porque el hospital les sigue el comportamiento mientras están tomando medicamentos
y luego unos examenes_ al año.
PR: Ayer también hablamos de que la manera de encontrar los casos agudos es ver los ojos, el
Chagoma, pero como Chagas a veces es asintomático. Hay problemas con encontrar todos los casos
(24:30)
JL: Realmente sí. Hay unos que se van quedando (escondido? skjulte?) que no se detectan a tiempo
porque...si es un niño___que el niño estaba con las síntomas a tiempo, no lo llevó al médico.
Entonces eso dependerá mucho de conocimiento de los padres. Ahora, hay muchos que se van
quedando..porque cuando ya los venimos a ver ya no tiene ningun síntoma y eso es el riesgo. Pero
la mayoría de los casos agudos son detectados porque tenemos en la mayoría de las comunidades
promotores de salud entonces ellos sí ya saben cuáles son los síntomas más visibles en la etapa
aguda..... porque (si?) en la etapa aguda no logramos detectar, va, y es bien difícil controlarlo. Creo
que hay un poco más de afinidad o de conocimiento para detectar un caso agudo a tiempo. Sin
embargo, nos presentó uno que a los médicos se les fue y el compañero de Malaria de vectores lo
descubrió, lo vió, y preguntó a la niña ”cuánto tiempo has estado con el ojito___”....pero ya llevaba
22 días...ya el ojito iba descendiendo....como me imagino que mencionó la Dra., no es el 100 por
ciento......es un porcentaje como el 25 por ciento de los casos que (får, udvikler) ese signo de
Romaña. No es el 100 por ciento de los casos que lo van a desarrollar. Ahora el Chagoma sí, (la
excisión) donde la chinche__siempre va a ser de color rojo y más grande, pero el signo de Romaña
no tiene todos los casos....y los otros que no presentan los síntomas como la fiebre alta
PR: También hay iniciativas que se hacen desde las comunidades. O sea que vienen de ellos. O sea
que los miembros de las comunidades hacen sus propias iniciativas o propuestas para el programa.
O más bien vienen del programa? [Telefon ringer i øvrigt – vist nok Dra. Gavidias]
(26:52)
JL: En realidad todo va en la vía de nosotros como programa de vectores. Las comunidades hoy
empiezan a solicitar o a proponer algunas soluciones a sus necesidades. Pero es bastante difícil
porque ellos se enfoquen más que todo en...mejora de infraestructura en la comunidad como una
calle, como una casa comunal. Entonces son cosas que para ellos son más relevantes____con lo que
es el Dengue, sí, hay algunas que están trabajando y es raro el municipio que dice ”vamos a rociar
nuestras viviendas”. Por ejemplo donde hicimos la encuesta serológica en San Pablo Tacachico, ahí
sí, la comunidad dice ”nosotros vamos a rociar”. Nos llaman y nos dicen ”para tal fecha vamos a
rociar, vamos a fumigar para eliminar la chinche.” Pero no es.....es bien mínima la cantidad de
comunidades que sí – solicitan un apoyo. Más que todo es el enfoque es la fumigación para el
Dengue
.....
También hay campañas de limpieza en las comunidades____y ellos solicitan el apoyo....hay
comunidades que están organizadas y otras que no....por ejemplo en Chalatenango..hay tres
comunidades que están organizadas..ya existe mucho...trabajar con el saneamiento básico...pero el
rociado.....en Tacachico donde es que la comunidad dice ”queremos rociar” y se___(henvender sig)
al promotor o el director de saneamiento o la unidad de salud para que ellos gestione los insumos y
ellos pueden trabajar.
PR: Ayer también hablamos un poco sobre la reforma del sistema de salud en (el) 2009, y en su
opinión ha cambiado la actitud de las comunidades? O sea...con las RIISS – es más fácil para la
comunidades ser atendidas
(29:04)
JL: Sí sí, porque aparte de aumenta el número de unidades comunitarias, hay más promotores, hay
más recursos. Entonces eso significa que por cada 350 personas, por cada 300 personas, hay un
recurso que les va a dar. No la atención total, pero sí va a detectar las necesidades de salud
más____(latente?) en este momento y va a crear el lazo o la cadena de servicio hasta que éste llega
a recibir un___necesario en el hospital del tercer nivel.
PR: Perfecto, y eso significa que tienen más posibilidades de ser atendidas la gente
JL: Así es.
PR: Pero también realmente utilizan esa posibilidad de ser atendidas o no saben
(29:51)
JL: Realmente las utilizan. Porque siempre están consultando, siempre están preguntando. Aunque
en nuestras comunidades...muchas veces el hombre no consulta...por una fiebre no siempre va a
consultar. (con una fiebre no va a consultar?) A veces dejan que vaya pasando...a veces
automedicamos....no creemos en médicos nosotros mismos [griner lidt]...vamos a comprar una
Acetaminophen [lig paracetamol]...con esto se me va a quitar. Pero no somos muy prestos a
demandar el servicio.
PR: Y los estudios serológicos en los niños menores de 15 años – eso se hace todavía
(30:35)
JL: Realmente, eso se consideraron como__piloto. Ya no se está haciendo. A menos que sea una
casa donde se encontró chinche positiva. Ese, sí se refiere, pero coordinado___esta familia.. tiene
dos niños y picó al papá...y se descubre Chagas crónico, se les mandan los niños. Pero eso depende
de la cantidad de insumos que haya en el laboratorio para poder hacer las pruebas......(mencionó)
Ing. Romero______a veces los proveedores de las pruebas no están a la mano a tiempo, verdad? Lo
otro es que tiene un costo bastante elevado...no podemos decir ”a esta comunidad le vamos a hacer
el 100 por ciento” sabemos que es bastante recursos. Aunque si contasemos con eso podríamos
hacer, pero es bastante complicado.
PR: Y los recursos para esas pruebas vienen de afuera o del Ministerio de Salud, o de la OPS?
JL: La mayoría de las veces los estudios se han hecho con el apoyo de la JICA y la OPS. Porque el
Ministerio se cuenta para ir haciendo los casos que ya son...conexo a casos positivos o crónicos o
que haya una chinche positiva.
PR: Al final quisiéramos saber un poco sobre su opinión sobre cuáles son los mejores beneficios del
programa de Chagas desde el inicio en el [2003] hasta ahora y también para el futuro?
(32:18)
JL: Bien, los beneficios son de que...al tener el sistema nos ayuda a captar más fácil los casos. Los
beneficios porque podemos ir trascendiendo...ya no de aplicar insecticidas, sino que las personas
pueden encontrar diferentes formas de evitar el vector. Por ejemplo, una casa limpia. No es
necesariamente es que tener una gran___bien construida, sino tener una casa limpia son las
actitudes que yo manejo diariamente para estar eliminando, y sacando todos los enseres que yo
tengo para evitar que el vector conviva con nosotros. Y lo otro es en la mayoría de los casos todos
los médicos....ya sea_en el sistema_año social__son capacitados para ir detectando de la mejor
manera los casos. Las autoridades también..al nivel superior están pensando que la enfermedad
existe y que hay que seguir trabajando. Y en realidad el personal de los otros niveles___como
promotores de salud, inspectores, éstos ya tienen la conciencia que existe la enfermedad
PR: Y también ha fortalecido el sistema de salud en general o en otras áreas que Chagas el
programa, en su opinión?
(33:44)
JL: Sí, se ha fortalecido. Por ejemplo, la unidad de vectores ahora es parte de la unidad de
saneamiento ambiental. La unidad de vectores no tenía...digamos la atención que ahora tiene
porque..saneamiento ambiental genera algunos fondos. Entonces con esos mismos fondos pueden
tener fondos para (palear- skovle) algunas necesidades.
PR: Y de esa manera se ha fortalecido el procedimiento para todas las enfermedades vectorizadas
(34:19)
JL: Así es. Porque hoy contamos para....se trabaja con un sistema única de información que no es al
100 por ciento para todos las enfermedades pero por ejemplo lo que es la de mayor relevancia que
es el Dengue que año con año (nos) demanda mayor tiempo..nos demanda un 80 por ciento de todo
el tiempo, de las actividades. Esta tiene un sistema de que cualquier información, cualquier
actividad que se haya hecho, un caso que usted busque, lo encuentre en este momento en el sistema.
Igual lo de Chagas, si hay un caso crónico o que no se han hecho pruebas iba a aparecer que le falta
las pruebas o que no ha recibido medicamentos o el seguimiento y eso nos permite nosotros...ya no
estar contando con un gran cantidad de documentos y papeles para ir a buscar un caso, sino vamos
al sistema y ahí vemos si le ha dado seguimiento.
PR: También quisiéramos saber un poco sobre los retos o los desafíos del programa, y en su
opinión, cuáles son los mayores desafíos ahora en la prevención del Chagas?
(35:28)
JL: El mayor reto sería cortar la enfermedad de (un) tajo. Como eso es paulatino, no se puede lograr
todo hasta que no mejore las viviendas. Eso sería el reto más grande para poder cortar la cadena de
transmisión, tendría que cambiar el aspecto social de las comunidades de mayor riesgo...digamos
éstas que están a indicadores...del 10 al 20 por ciento para arriba que son.....y lo otro es poder hacer
serología. No solamente cuando hay casos, sino que considerar un porcentaje de la población,
digamos de las comunidades de riesgo - rurales más que todo donde los indicadores entomológicos
están presentes. Eso sería un reto bastante grande porque nos permitiría a nosotros decir....bueno lo
ideal sería no casos, verdad? Y aunque no me salirían casos, yo podría decir ”esas comunidades
están libres del parásito. Porque muchas veces no se cuenta con el 100 por ciento de la logística
para poder llegar a tiempo para controlar un caso..y como el vector vive 2 años, nos da tiempo para
cortar esa cadena pero demasiado tarde ___sin embargo cuando estamos viendo...haciendo
serología y rociando, viendo que las cosas van caminando a la___?
(36:59)
PR: Al final, sólo quisiéramos saber si en su opinión hay algo importante sobre lo que no hemos
preguntado o si hay algo que usted desea añadir?
JL: Pues, no, creo que todo está bien.
Derefter: Aftaler vi fredagens field trip...ikke noget om projektet...
Interview with Shinji Sato, Senior Representative JICA El Salvador, María Alvarado, Official
of JICA El Salvador, and Angelica Castillo (who was present but did not participate actively),
Official JICA El Salvador, December 16th, 2015
... = pause in the speech
__= can’t hear what is being said
[ ] = when something is understood but not being said
( ) = If I am guessing a bit about what is being said from the context fx.
directive/guideline/norm = la Norma Técnica 
[introduction + we ask if recording OK  MA starts to make a presentation about the documents
they have given us and a general presentation of the program]
MA: Well, it is a pleasure. It is very interesting that you are investigating this, the theme of
Chagas...in the region [Central America]. We have given you some folders in which there is some
information...a summary of the Chagas project in phase 1, in phase 2, and some information which
Mr. Hashimoto worked on for some time [his book], and this document which is a book of best
practices, which is just what you are trying to investigate. Perhaps I can make a summarized
explication about a bit of the path of JICA’s support in this country, and it was in the year...phase 1
of the Chagas disease control began in the year 2003 to 2007...the japanese cooperation is
principally focused on strenghtening capacities...of the governments at the institutional level, of the
human resources, and in this case also of the persons at community level. We worked with the
Ministry of Health, which was the principal counterpart, and also with the communities in
coordination with the local governments [municipal, regional]. The theme of training the health
personnel was a part of the work, principally so that they in turn would work with the
communities...and also training the persons in the communities to carry out self-care...such as
surveillance, let’s say, of the vector, in this case the kissing bug in their houses...such as keeping the
home clean, tidy...certain features so that the person himself could do this monitoring in their
homes.
The Japanese cooperation donated equipment, vehicles , motorcycles, and other things in order to
access the very...very complicated places. This project [phase 1], I think that Ing. Romero explained
the information in general, was carried out in the western zone because of the high infestation
rates...and many important changes, let’s say, were achieved in the communities with this process
through the work of the Japanese expert...there was a coordinating expert, and short-term experts
came to work at community level. There was a production of diverse educational materials, and
some of theme adapted to the community language to facilitate understanding, and also videos that
were shown on the national channel...so that the children could learn on a national level. There was
also focus on that theme of working with the schools. And the first agreement between the Ministry
of Education and the Ministry of Education emerged, first in one region...and that was like...it set
the tone so that later an agreement was arranged at the ministerial level [national level]...at the level
of the Ministries of Education and Health which has contributed a lot in the educational
component...and I think that those things have been...like the model...the path to the successes and
advances that El Salvador have achieved.
In general there was a focus on those components in phase 1...education in the communities and in
the schools...it was called the attack phase...as a process of spraying was done in the homes which
were infested with chinches, and the families were educated in making changes...changes of
behaviour so that the chinche would not return because if they put some...like calendars or things
like that, the chinches...it was identified that the chinches would return [they can hide behind
calendars on the walls for example]. So there was this whole process in that first phase of the
project in the western zone...and the strengths were, in my opinion...that part of education;
education at the level of the Ministry, at the community level, and that interinstitutional linkage
with the Ministry of Education, mayors’ offices, and local actors...some NGOs also collaborated in
the theme, for example Fundasal, an NGO which was also collaborating...that was like phase 1...and
perhaps a very important component that I would like to highlight is that as a part of JICA’s
cooperation schemes there is a dispatch of Japanese voluntaries...so the dispatch of these
voluntaries...they came for a period of 2 years, and they worked hand in hand with the communities.
So that was very important because...there was an expert at the central level who coordinated in
general but the voluntaries were strategically [placed] in some places to make the [local]
coordination, and principally the educational part with the communities. I think that they are some
of the noteworthy actors in this process.
Later phase 2 of the project emerged from 2008 to 2011. Now there are like 2 big lines of work...
What had already been achieved in phase 1...well the idea was to strengthen it and establish a
monitoring system with community participation, and in the other departments which were
incorporated in phase 2, which were in the eastern zone and also the central zone...to transmit what
had been learned, so that those other departments also benefitted from the lessons learned and
everything from the phase of the western zone [phase 1]...and in that sense...even though only 7
departments were part of phase 2 – we have 14 departments in total in our country – so we were in
half of them...covering the half of the departments of the country. But for example, there were
training activities or evaluation workshops to monitor the progress...all of the 14 departments of the
country were gathered in these. In that sense, even though the focus group was 7 departments, there
were activities at a national level.
So there was also work in...the matter of community surveillance was strengthened even more...that
was like the strength in phase 2, and the agreement which emerged...that framework agreement
between the Ministry of Education and the Ministry of Health, and the National Chagas Day was
introduced, in the beginning with a resolution of the Ministry of Health but since last year there has
been a legislative decree...which in a way commits the Ministry of Education to...let’s say promote
the theme to the students...the theme of Chagas was also included in the textbook of natural
sciences in the 6th grade. It has not been diffused that much in the other grades but it was like a first
initiative. I think that in this whole process the important thing was that...when it emerged, well, the
project has had a very important support in the political management...there was much support from
the authorities...in the previous government [first FMLN, from 2009] the Minister of Health was
one of the first investigators of Chagas. So that was like a very...a very big advantage for us, JICA,
and for the Ministry because there was an opening...the institutional commitment...also to use the
Ministry’s own budget to cover...the costs of for example insecticides and other materials or
treatment for the patients...and PAHO has also played a very important role in this whole process in
the matter of medicine and other measures, for example to support that some experts or lecturers
came for some events. So there has been like a...it was like a whole process of collaboration
between the Ministry of Health, JICA, PAHO, the Ministry of Education, some NGOs...for example
the Red Cross also made a project at some point...taking up the lessons from the country.
So all of this was strengthened at the level of the Ministry of Health...the management of the
national Chagas program...I think that those have been the key aspects which drove this project to
have success, and they [the aspects, activities] remain with the Ministry of Health...and as they told
you, Ing. Romero and his team continues with technical aspects. They continue working and
developing the activities because...the problem with Chagas is that if follow-up is not done, the
things that have been achieved over a year for example, they can be turned back, it can regress. So
they [MoH] are with this process...there is a very important advantage in the country, and that is
that the Ministry of Health has health promoters at its disposal. So they are in the communities, and
with the project it was achieved to include the theme of Chagas, the surveillance of Chagas, in the
work, in the work profile of the promoters. I think that all these elements have also helped the
Ministry of Health so that it can continue working...and work was also done in supporting with the
regulatory documents, for example the technical Chagas directive/guideline/norm, or the technical
guidelines to do the spraying and questions like that, and the matter of education. As I mentioned
before, a lot of promotional materials, educational materials were produced with the project, and the
Ministry even has these in its website which everyone can access. So in general terms these are the
things that were done...the Ministry, that commitment also continues. Now, for example the
directive/guideline/norm of Chagas is integrated with other themes but always with a view to
continuing this effort. So I also think that the commitment of the persons, who have led the national
Chagas program, has been very determinant. And in turn they support the local levels from the
Ministry of Health.
PR: Well, in the first place we have some questions about the division of the work. We have read
the JICA principally has supported in the chemical control, in the entomological investigation and
surveillance, and the strategy of information, communication and education, while the national
program has had the responsibility of diagnosing, treatment, and the interruption of the
transfusional transmission of Chagas. And we would like to know why that division of the work
was chosen? That is, why...were these the areas in which JICA was going to give its support?
MA: In principle the support of the Japanese cooperation is oriented at strengthening the capacities
of human resources...the preventive part. So parallelly...as the Ministry of Health is the entity in
charge of facilitating and providing all the services, doctors and everything, so I think that, that was
JICA’s reason for helping, in one part, in the question of identifying problems related to Chagas
cases. JICA also provided training in the theme of...identification of cases, for example in...there
was a course in Argentina and there was personnel who did a diploma course in medical
entomology...but that being said, the role of the Ministry of health...has always been respected,
right? They are the specialists in detection and treatment of patients...there was also a process of...in
a national Chagas conference which took place where investigators from Brazil and other
Southamerican countries were brought in...of recommending to the Ministry of Health that the
Chagas patients...well, in the acute phase they facilitate treatment to all the patients but not in the
chronic phase. So according to that investigation [presented at the conference] they explained that
even the chronic patients can improve their quality of life with this...giving them treatment. So it is
like that...in the case of the next directive/guideline/norm they [MoH] are envisaging to include this
treatment [of chronic patients].
So in sum I would say that the division [of responsibilities] was...perhaps we did not view it like
that...as a division, right? ”I take care of this and you of that”. Because by nature JICA...we develop
the projects jointly with the institution...the planning, the execution, everything...and for example
the principal role of the counterpart, the institution in this case, is always respected.
PR: And the areas in which JICA has participated a lot...how did the strategic planning function?
That is, between the Ministry and JICA. Who had the command?
MA: Well, from the beginning when the project application is made, there is a joint work between
the Ministry of Health, or the interested ministries, and JICA of planning or formulating the project.
So from then the teamwork begins. And later when the project is approved, the delegation comes to
discuss jointly with the ministries. Meaning that there was not like...someone who commands more,
it is rather a team. So, JICA supports the Ministry but it [JICA] also make suggestions according to
the expertise or experience which it has. But it went like that...discussing on even terms about what
was the most convenient for the execution of the project...perhaps I should explain it a bit to you...in
these projects...there is a general structure which JICA manages...a joint coordination team is
conformed, and it is like the...executive management of the project, and later a technical team. So
that joint coordinating committee is the one which validates the plans of work, strategies or...the
problematics which can emerge. And that is how it is managed like...in a strategic coordination or
planning but in a joint manner.
PR: And also...the responsibilities which JICA had...how were they transferred to the national
program?
MA: They are transferred during the process of execution. As the fundamental idea is to transfer the
knowledge to the national counterpart. So [it is transferred] during the work, the planning...for
example the development of activities is done together. In this way the activities are developed
jointly, and the...commitment, the role is taken over when the projects are executed because there is
a coordinating expert who works hand in hand with the Ministry but when the project is
finished...there is a process of transferring this responsibility and this whole development of the
activities to the institution. So all this [the transfer] is carry out during the exection of the
project...that’s how it is.
PR: And in your opinion, to what degree have the persons of the national program become capable
of carrying out all the activities in an independent manner now?
MA: I think that there is a very high degree of capacity. Sometimes the limitation that they have as
Ministry is budgetary questions, or related to human resources. But the technical capacity...the
Ministry, the team that we worked with...it is a highly qualified team.
PR: Well, we have also read that JICA has made a lot of support in the strengthening of the
communication between the different levels. The central level, the regional level, and the municipal
level. For example through the voluntaries. But apart from these voluntaries, how was the
communication strenghtened specifically?
MA: Yes...the Ministry has that structure, right? The central level, the regional level, and the
community level. So the work was done taking into account the three levels, for the planning of
workshops or the different activities. Everything was always done through the national coordinator
of the program but he depended on a management [team], on a unit. So through them there was a
flow of information. But in that case the expert who was running the project, he had access to any
of the levels...always with the communication...the coordinator of the national program.
PR: And in your opinion, can that strengthening of the communication also be used in relation to
other health themes, and how?
MA: Yes, the truth is that...with the Chagas project a linkage was created at central level, at regional
level, and at community level. In reality the Ministry manages that structure for all its tasks. And
perhaps the important matter in how it can be used for other programs is for example how the work
is done at the level of health promoters, and that they are the operative level because they are the
ones who are present in the communities. So that structure [with linkages between the different
levels and with health promoters in the communities]...I think that it is very important for any type
of health problem...with Chagas or Dengue, or what is might be...it is useful, you know?, in the
sense of managing the different levels...different levels of management, for example the community
level sees the day to day problems of the communities. So they transmit that to the intermediate
level or the regional level...and if they don’t get a response there, they __ (declare) it to the central
Ministry. So they see that __ as very opportune in order to be able to use it for any type of health
problem.
PR: We have also read that in the beginning, at least, the data management and analysis was carried
out by Japanese experts but how has that function been transferred to experts from El Salvador
now?
MA: The analysis of the data, [was done in] the Ministry’s own system when the project began...the
Ministry of Health has always managed a system of...where they manage all the health indicators.
But the Ministry itself was...improving this [system], and what was done with the project was to
give feedback to the Ministry’s system. So it could be considered to be a process of transfer but it
was already the Ministry’s own system which did not emerge with the project.
PR: Another thing. Was it the intention of the program that for example the integration of
technicians from different disciplines and the training in the data management could be used for
other health themes as well, or in relation to other diseases?
MA: I think so. The thing is that for example in this case the focus was on the theme of Chagas but
as the experience which was gained by the Ministry for example...and in the meetings it was
discussed that it was very important that they [MoH] took into consideration to implement it, for
example in the case of Dengue, to give you an example...it is the same type of information
management and also the theme of training the communities...because it is...it is there, right?...there
is a management of information but that information comes from the health problems of the
communities.
PR: You also mentioned the collaboration the collaboration between PAHO, JICA, and the Ministry
of Health, and well, we would like to know what the biggest benefits have been of that
collaboration between 3 actors?
MA: For the Ministry of Health they have been...the benefits in the sense that for example in the
case of PAHO...well, the principal actor was JICA in any case, right? [it was more principal than
PAHO, not the MoH] because [it was] in the operative, and PAHO was a collaborator...for example
in the case of providing medicine and things like that and other technical questions...the Ministry of
Health also had that accompaniment of PAHO.
PR: And how were the dynamics between the 3 actors? That is, how were the agreements made and
all that...were there challenges in the collaboration?
MA: In the case of the Ministry of Health with the Ministry of Education...well, in the particular
case of PAHO it was in specific questions...for example it was not the case that PAHO was in the
whole development of the project but they for example in the case of...no, this is the discussion
summary, the official document of JICA with the Ministry [she is talking about one of the
documents which they gave us in the beginning of the interview]...or in the evaluations, there was
always participation, presence of someone from PAHO but as an honorary witness, in that
category...PAHO was not like an implementer of the project but rather a collaborator for the
Ministry in certain specific questions.
PR: I think that the next question is more for you, Mr. Sato. We would like to know what the
motives were, also for the Ministry of Health but also for JICA, of choosing a very vertical
approach...that is, an approach directed at a specific disease instead of an approach directed at
improving the system in general? And also, what have been the benefits of that approach?
SS: Well...from my point of view, JICA’s project about the theme of Chagas is not a project of
controlling a transmissible disease but rather in aspects which are more...well, a characteristic
which is more...very symbolic...to support the health system. In that sense...well, it does not matter
if it is Chagas, if it is Dengue, or another disease but the most important thing for us...well,
obviously [also] for the Ministry of Health is to establish a work mechanism from top to bottom and
from bottom to top. As you mentioned, clearly it is a matter of communication. So the other theme
which was very important for us with this project was the counterparts from the Ministries of
Health...now they have, they recognize the importance of taking reactions based on evidence...so
until the implementation of this project the officials of the Ministry of Health had been working but
not based on some evidence, or data, right? So based on some data they have to plan...their
fumigation, right? To give some medicine to the population...but they always have to have data,
evidence. With JICA’s support they took into account the importance of managing that type of data
and use it in their planning. So, the counterparts of our project have certainly been trained and
strengthened in that management of evidence. And that is not a benefit for the control of Chagas but
for all [health problems], right? For the control of all diseases...and perhaps apart from disease
control...well, control of aspects...aspects in the field of health. Because we are talking about
improving the health system. So...our idea of working in this field with the Ministry of Health is
...to establish a model of work for improving the health system in this country...I am not only
talking about this country but also Guatemala, Honduras, Nicaragua...for all of them. So in each
country they have their own model established through our Chagas project. So our idea, our desire
is...to replicate this experience to other diseases...to find...in these countries. In this way it is very,
very...our project was very, very specific. But we are very certain that it has been converted into a
model of how to improve the health system.
PR: And according to your experience, is this approach with emphasis on data and evidence used in
relation to other disease as well?
SS: I’ll tell you frankly, I am not sure. I am not sure how the Ministry of Health is using that
technology, that capacity...I don’t know exactly. But at least for the theme of Chagas, even though
we are not carrying out a cooperation project in Chagas [anymore], they are working, they are
continuing with the experience of the project, for example Ing. Romero. So at least for Chagas
control they are working with a mechanism which is already established.
PR: Yes, we understand that it was also one of the most important objectives that they were going
to continue with the approach...we also have some questions about the collaboration with other
actors. You [MA] mentioned that there has been collaboration with some NGOs...and well, has
there been collaboration with many actors or organizations from civil society who don’t belong to
the health system?
MA: Well, there was this collaboration with the NGOs of Fundasal which was focused on the
construction of homes...
PR: And Fundasal, where is it from?
MA: From here.
PR: From here?
MA: Yes. And...so through the Chagas project they focused their project on that, and they used
materials which were developed for the project. So the coordination, collaboration with them was in
that sense, in the theme of training or facilitating part of the promotional materials or facilitating
materials...also including the theme of training the persons so that when they were constructing
homes, it was of course not going to be that susceptible...the home...to the chinche...but they came
to have the mentality of carefullness and the part of education.
PR: And how were they selected, these actors...that is, did they volunteer, or?
MA: The thing is that as the project became known [to the public]...so in this case the NGOs which
were very interested in the matter or in supporting the Ministry...at some point they met with the
project...with the experts of the project.
PR: And did they contribute with their own inputs or own resources?
MA: They had their own inputs or management. For example in the case of Fundasal...their own
resources...in the case of the Salvadorian Red Cross, it implemented a project in the eastern zone, in
Usulután...and they managed funds, it was even with funds from Japan but through __ [maybe
another organisation, sounds like VIR]...it was like their own management of a project in
community work.
PR: Has there also been collaboration with religious actors in the theme of Chagas?
MA: The religious sectors...I don’t know because...we at the level of the officed do not participate
in a 100% of all the activities but in the communities in general. There [in the communities] were
persons from different sectors, you know?
PR: We also heard that the religious organizations get more involved in other matters. Is that also
your experience that they involve themselves more in other health themes and in other community
matters?
MA: Well...I don’t really know...
PR: OK. In our interview with Ing. Romero and Dr. Gavidia we became aware that the national
program asked JICA to continue with the support [to the Chagas program] but that JICA estimated
that the national program was ready to take up the complete responsibility of the program, and we
would like to know how that evaluation was made?
SS: Well, perhaps I have to answer...the thing is that I am the person who...[laughs]
MA: You said ”no” [laughs]
SS: Before coming here I worked as a director of an office which managed the health projects in
Latin America...including the Chagas projects in Central America. So in the years of 2010, 2011,
2012...in thise years the Central American countries achieved international certification...for
example the elimination of a species here in El Salvador...in 2010, right? So in 2011 Honduras,
Nicaragua...like the interruption of transmission...so in that sense each Chagas project had already
achieved great results...so there was no...and they knew that as well, the presidents of JICA in Japan
[about the results]...so they said ”why do we have to keep on working, [why] do we have to keep on
supporting the countries which have already achieved some concrete goals?”, right? So that is why
we have taken that decision that we are not going to keep on working in the same way, not in the
same way. But in that moment we took the decision to send an expert, Mr. Hashimoto, to gather the
best practices of each country in Central America so that later the Ministries of Health of each
country take into account those best practices...and as an example for the improvement of the health
system, no only related to Chagas but also related to other diseases...that was our idea...so we have
changed our strategy of supporting Chagas programs a bit...not [supporting] directly but to gather
information and best practices so each Ministry of Health would taken them into account...that was
it.
PR: And apart from the interruption of transmission and the elimination of Rhodnius prolixus, were
other indicators used to evaluate the programs 3, 4 years ago?
SS: If we are talking about evaluation...evaluation by JICA, yes, we always operate with a
framework for any type of cooperation project...there we have...well, project objectives, project
results...expected project results, and the program and the activities were based on those expected
results...so at the level of the results and the project objectives there are some established
indicators...normally at the beginning of the cooperation project. Obviously, they are shared
indicators between the Salvadorian part and the Japanese part. So upon finalizing any type of
technical cooperation project we carry out and evaluation based on those indicators. So in the case
of the second phase of the project, the Chagas project here in El Salvador we did a final evaluation
of the project in 2011. So fortunately, in that moment we had achieved a high level of fulfilment of
the indicators so we officially determined that we were going to finish the Chagas project phase 2
here in El Salvador. But there are always cases of...when we do this type of final evaluation, and we
cannot see that the objectives of the project __ __ (have been achieved)...there is always the
possibility of prolonging the project a bit.
PR: And in your opinion, have there also been achievements that cannot be measured, that is,
achievements which cannot be shown in the same way?
SS: Perhaps...if we are not only talking about quantitative indicators but [also] qualitative...from my
point of view...in this project, phase 2 of the Chagas project, we focused more...in the second phase
of the project...like on surveillance where we needed more community participation...and evaluating
the community participation is extremely difficult, right? But...I’ll give you an example...when I
visited a health unit/center in Ahuachapán, in the west of this country in 2013...in that year we had
already stopped implementing the Chagas project...I visited a health center. There was a small box
for chinches...a box...when a person or some inhabitants find a chinche in their house...best to grab
it with a bag, and they bring it to the health center, right? It is a work established within the
project...so that the health center take into account that a chinche has been found. So there is a need
to visit and to do fumigation. It is a monitoring mechanism established in the Chagas project phase
2. I saw that it was working, this mechanism even though we had already stopped implementing the
project in 2013...so that is an example...and perhaps it is a sign that each community is showing its
interest in participating.
PR: Perfect. We also made a visit to a health center in San Pablo Tacachico in La Libertad, and
there we became aware that JICA have supported the promotion activities a lot, and that it has been
a very important support for them. However, they told us that now there are fewer resources for the
promotion activities and also for materials, and also that more resources could be used now...in your
opinion, how can that situation be improved?
[laughs]
MA: I will give you the word.
[laughs]
SS: Perhaps...it is not an issue which is directly caused by...by a lack of initiative or motivation of
the personnel of the Ministry of Health but rather sometimes...related to vector control the Ministry
of Health always has to put the priority. For example if Dengue cases increase, the person has to
work hard with that issue, right? And obviously, they do not have sufficient human resources to
deal with Dengue, Chagas and other diseases at the same time. So it is always necessary...they
always have to put the support in their work. So we know very well that the control of Dengue and
other diseases have a bigger budget than that of Chagas. Therefore it is always termed as
a...neglected disease...so perhaps they have to improve that situation themselves because...I repeat,
they already have much knowledge, they are qualified to work based on evidence...so if it is that
Chagas cases increase, they can present that data to obtain their own resources to strengthen their
work with Chagas...that is what we are hoping...and well, it is very easy for us to talk to the
Ministry of Health, asking them to increase the budget for Chagas but that is not...it does not
work...it does not always work. So perhaps it is better that they...it would be better for them to use
their capacities which have been strengthened in the project.
PR: A bit related to this...according to your experience, how is the theme of Chagas viewed among
the other themes of health such as Dengue or Malaria or other health problems?
MA: The theme of Chagas...well, the theme of Dengue has always had a high priority because
Dengue affects the population in general, regardless of the social stratum. It is not like that with
Chagas. However, with the project it was achieved to advance it and make visible, let’s say, the
necessity of putting your eyes or resources on the theme of Chagas...and as I mentioned earlier, it
helped that fortunately the Minister [of health] was a person who was knowledgeable about the
theme, and there was commitment, in humanitarian terms, to the people with scarce resources, and
apart from that...that difficult situation in economic terms they [people with scarce resources] were
suffering from the problem of Chagas. So yes, there was a recognition but I think that perhaps it is
not a high priority to see their other diseases [the poor’s other diseases not a priority]...to see their
Dengue or some other ones such as Chikungunya which is one of the diseases which has appeared
now.
PR: Another thing...in the correspondence between you, Mr. Sato, Mr. Hashimoto and ourselves
you mentioned that it is difficult to find safe places for JICA’s voluntaries to work and to stay
because of the crime situation in the country...and we would like to know if the insecurity of the
country has affected the Chagas program and how?
SS: Normally our voluntaries have to work in the field, right? So I am referring to...living with a
Salvadorian family. That is normal for our voluntaries...so the theme of security is extremely
important for the dispatch of voluntaries...but for example in our office’s security regulations...more
than 30 municipalities are not adequate places for our voluntaries to work...so, well, some places are
are included [on that list] which have earlier been...part of the Chagas project but because of the
security issue we cannot send out voluntaries...but perhaps...we have one voluntary who are
working with Chagas in Santa Ana...there, yes, and we do not have security problems...but...each
year we have to revise our security regulations based on the realities of the country...it is a very
regrettable situation for us but the security for our voluntaries is the most important thing.
PR: Now we would like to know a but more about the benefits and the achievements of the
program, and in your opinion, apart from the strengthening of communication and the use of data,
what have been the biggest benefits of the involvement of JICA in the Chagas control?
MA: I think that the biggest benefits are in...have been in the population which was not affected and
through the processes of education, for example with the students or with the community...they
were not affected for example...because even during the project many doctors did not have
knowledge about Chagas...meaning that it was also a process of education for the doctors...I think
that one on hand, the part of promotion and education...was one of the important benefits for the
population.
PR: And do you also think that the health system has been strengthened in other matters apart from
the communication and that approach?
MA: I think so, in the part of...well, within the Ministry there is a unit called Health Promotion, and
Health Promotion is for different thematics...there, I think that they have learned a lot about the
theme of...and the work methodology of the Chagas program. For example, that educational part
with the community and that community participation, in those things, I think.
PR: And in your opinion, what are the biggest challenges in the prevention of Chagas now?
MA: Now we are not making that close a follow-up [so she doesn’t know that well] but...the
challenges in budgetary terms is one which...as in everything, as I mentioned [the budget is a
challenge in everything]...but I think that the challenges are, and were also during the project, the
rise in cases, principally of Dengue...so for example even with the project, when we were part of it,
even though we had workshops...if Dengue shot up, which happens each year, all the activities in
other themes are obstructed...I think that it can be one of the challenges...the __ (need) to dedicate,
to attend to other epidemics which emerge on the way, you know, in the different periods of the
year...I think that it would be...I think that it would be one of the challenges...there will certainly
[also] be others.
PR: And according to your knowledge, han new challenges emerged since JICA ended its part of
the program...for the national program?
MA: I think that, you know, in terms of monitoring there was like follow-up and evaluations with
the project every 6 months. Now they do it but not like that, like with that level of periodicity, with
that level of follow-up because there was an expert [during the project]...I think that maybe it has
diminished, even though they do follow-up...but in general for other thematics.
PR: Another question for you, Mr. Sato, you come from a place very far away, and you also worked
in other matters here in Latin America. Have you seen work conditions here that are specific to
Central America and El Salvador?
SS: Before I worked in JICA’s office in Bolivia from 2002 to 2006...well, comparing with that
experience in Bolivia...the Salvadorians are not that Latin American [laughs]...the are...very
exacting in their work and hard-working...so for me it seems...that sometimes they are too serious in
their work...but maybe that is a very representative characteristic of this country and the people
too...and that helps us a lot...not only in the Chagas project but for any technical cooperation
project...we always have a counterpart which is very enthusiastic to work with us...very committed.
So yes, that helps us a lot.
PR: And in what way has it been necessary for JICA and yourself to have an open mind in relation
to other ways of working, or has it not been necessary? That is, how has it been necessary to have
an open mind to other ways of working?
SS: [laughs] until now I have not thought that much in that theme [laughs]...but...how do I say
this?...in English they say __ (division)...perhaps that is a very representative word about this
population...and I am not only referring to...how do you say...to focus your work but also with your
colleagues: always hard work [work and play not mixed, I think]...so that has a very big impact
when we, the foreigners work together with the Salvadorians.
PR: And how have the [JICA’s] experiences from Guatemala with Onchocerciasis and the
investigations in tropical diseases been used here in El Salvador by JICA?
SS: That is, using the experiences from here in El Salvador in other countries, or...?
PP: Also...but also the experiences that they [JICA] had from the programs of the 70s, 80s, and 90s?
SS: As you know, with Chagas we began our cooperation in Guatemala...and there...that projects
was very...not that traditional...I repeat, the thing is that this project of technical cooperation in
Chagas is not a project of control of a transmissible disease but rather a project to establish...to
improve the health system...so, in that first project in Guatemala they did not have a doctor as the
expert...they only had an expert in coordination with the group of voluntaries who work in the
field...they were neither specialized in medicine...but they worked as if it was community
development...that was a characteristic of the first project of Chagas control in Guatemala, and in a
way that characteristic has been applied to each project in El Salvador, in Honduras, in Nicaragua...I
think that neither of the projects have had a doctors as expert...it is always an expert but in
coordination or in...how do you say...social investigation...that type. So...perhaps an experience, our
experience in Guatemala...we have replicated it in all the Chagas projects in Central America.
PR: And which activities are carried out by JICA now here in El Salvador?
SS: Related to Chagas?
PR: No, related to other themes.
SS: Yes, we have...well, were are talking about the projects now...but well, on top of those
projects...we have some cooperation programs. As of now, we have 2 cooperation programs __ here
in this country. One is a development program in the eastern zone...it is territorial development...I
am referring to 4 departments in this country, Morazán, La Unión, San Miguel, and Usulután, 4
departments. And another program which is risk management as this country, not only this country
but various countries in Central America have the difficulty, the problem of risk
management...prevention of natural disasters...and as you know, our country, Japan, is also a
country which is very vulnerable to any phenomenon of natural disasters...so sharing our
experience, we are supporting El Salvador and other Central American countries...those are the 2
programs..__ __
...Peter, I have another meeting which begins at 3...so I am going to leave you here...is that OK?
PR: Yes, actually we only have a few formalities that we would like to mention...that is, we would
like to know if there is something important which we have not asked about, in your opinion?
MA: I think that in general terms it is covered, you know, the main lines of the work, the __, the
actors and coordination.
PR: Then just to explain one last thing, I don’t think that I mentioned it, that we do not have the
intention to publish this thesis but if we get the opportunity to do so in the future, we are going to
ask for you consent to publish it, and also another thing that you can remain anonymous in the
investigation if you wish to do so...and also, if you wish, we are very willing to share our data with
you and to send you the final project so that you can also read it when you have the time.
SS: Yes, I have quite a lot of interest...[laughs]
PR: Finally, we just want to thank you a lot for your time. It has been extremely informative for us,
and it helps us a lot to make our investigation and...we are very glad that you have taken the tiempo
to talk to us, and we are very thankful.
Entrevista con Shinji Sato, María Alvarado y Angelica Castillo (estaba presente), JICA El
Salvador, 16 de diciembre, 2015
[intro + spørger om OK at optage...]
MA: Bueno, mucho gusto. Es muy interesante que ustedes estén investigando eso, el tema de
Chagas...digamos en la región [CAM]. Les hemos compartido unas carpetas en donde hay alguna
información, resumen del proyecto de Chagas en fase 1, en fase 2, y alguna información de que
trabajó Sr. Hashimoto en un periodo, y este documento que es el libro de buenas prácticas que es
justo lo que ustedes están tratando de investigar. Quizás puedo hacer una explicación resumida de
un poquito del recorrido en el país con el apoyo de JICA, y fue en el año...desde el año 2003 al
2007 inició la fase 1 de control de la enfermedad de Chagas. La cooperación japonesa
principalmente se enfoca a fortalecer capacidades...de los gobiernos a nivel institucional, de los
recursos humanos, y también en este caso en las personas a nivel comunitario. Para ellos se trabajó
con el ministerio de salud que era el contraparte principal y también con las comunidades en
coordinación con gobiernos locales. Se trabajó en el tema de capacitación al personal de salud
principalmente para que ellos a su vez trabajaran con la comunidad. Y también capacitando a las
personas en la comunidad para hacer autocuido...como vigilancia, digamos, del vector...en este caso
la chinche picuda en su casa, como para tener limpio, ordenado, ciertas características para que la
persona misma fuera, estuviera con este monitoreo en sus viviendas.
(2:01)...de parte de la cooperación japonesa se donó equipos, vehículos, motocicletas, y otros para
poder accesar a los lugares muy...muy complicados. Este proyecto, yo creo que Ing. Romero
explicó en general la información, de donde se realizó fue en la zona occidental por los altos índices
de infestación...y se lograron muchos importantes cambios, digamos, en la comunidad con ese
proceso a través del trabajo del experto japonés, había un experto coordinador, y llegaban expertos
de corto plazo para poder trabajar a nivel comunitario. Hubo producción de materiales educativos
diversos y unos adaptados al lenguaje comunitario para facilitar el entendimiento así como videos
que se proyectaban en canal nacional para que...a nivel del país los niños pudieran aprender...se
focalizó también en ese tema de trabajo con las escuelas, centros escolares. Y ahí surgió un primer
convenio entre ministerio de educación y ministerio de salud a nivel de una región...y eso fue como
(marcó) la pauta para que posteriormente se gestionara ya un convenio a nivel de ministerios...a
nivel de ministerio de educación y salud que eso ha contribuido mucho en el componente de
educación...y creo que son de la...como de las pautas que han dado la...el paso a poder tener los
éxitos y los avances que El Salvador ha ido teniendo.
(3:38)...En general en la fase 1 se enfocó en esos componentes: educación a la comunidad, y a los
centros escolares...se llamaba la fase de ataque...es decir...como las viviendas que estaban
infectadas con chinches hacían un proceso de rociar, y educación a la familia para hacer cambios
de...cambios de comportamiento para que la chinche no regresara porque si ponían como
algunas...calendarios o cuestiones así entonces las chinches...ellos identificaron que la chinche
regresaba [de kan gemme sig bag kalendere osv.]. Entonces hubo como todo ese proceso en esa
primera fase del proyecto en la zona occidental...y los fuertes, a mi criterio fue esa – esa parte de
formación, digamos, educación a nivel de ministerio, a nivel de la comunidad, y esa vinculación
interinstitucional con ministerio de educación, alcaldías, y actores locales...algunas ONGs también
colaboraban en este tema, por ejemplo Fundasal, una ONG que estaba también colaborando...eso
fue como fase 1...y quizás un componente muy importante que quisiera destacar es que como parte
de los esquemas de cooperación de JICA hay envío de voluntarios japoneses...entonces el envío de
estos voluntarios...llegaban por el periodo de 2 años y trabajaban mano a mano con la comunidad.
Entonces eso era como muy importante porque...experto, había un experto, digamos a nivel central
que coordinaba en general pero los voluntarios estratégicamente estaban en algunos lugares para
hacer la coordinación y principalmente la parte de educación con la comunidad. Creo que son
como los actores muy destacables en este proceso.
(5:28)...después surgió una fase 2 desde 2008 hasta 2011. Aquí hay como 2 grandes líneas de
trabajo. Lo que ya se había logrado en la fase 1...pues se logró y la idea era como fortalecer y lograr
como establecer un sistema de monitoreo con participación comunitaria, y en los otros
departamentos que se incorporaron en la fase 2 que eran en la zona oriental y también en la zona
central...ahí transmitir lo que ya se había aprendido, las lecciones aprendidas y todo de la fase de la
zona occidental para que esos otros departamentos fueran beneficiados...y en ese sentido, aunque la
fase 2 habían solamente 7 departamentos – en nuestro país total tenemos 14 departamentos –
estábamos justo a la mitad, cubriendo la mitad de los departamentos del país. Pero habían acciones
por ejemplo de capacitación o talleres de evaluación para monitorear el avance que se iba
teniendo...en esos se juntaban a todos los 14 departamentos del país. En ese sentido, aunque el
”focus group” era como 7 departamentos pero habían acciones a nivel nacional. Entonces se trabajó
también en...se fortaleció aún más el tema de vigilancia comunitaria, eso era como lo fuerte en esta
fase 2, y el convenio que surge...ese convenio marco entre ministerio de educación, ministerio de
salud e instauraron el día nacional de Chagas en un principio con una resolución del ministerio de
salud pero desde el año pasado ya hay un decreto legislativo que eso...de alguna manera obliga a...al
ministerio, en [este] caso de educación, a promover, digamos, con los estudiantes en ese
tema...también se incluyó en el libro de texto de ciencias naturales de sexto grado ese tema de
Chagas. No se ha difundido como mucho, digamos, en otros grados pero era como un primer
iniciativa. Creo que en todo este proceso lo importante es que había...cuando surgió, bueno el
proyecto ha tenido un apoyo muy importante en la gestión política...había mucho apoyo de las
autoridades...en el gobierno anterior la Ministra de salud es una de las personas de las primeras
investigadoras de Chagas. Entonces eso, digamos, para nosotros como JICA y para el ministerio era
muy, muy...una ventaja muy grande porque había mucha apertura...el compromiso
institucional...para también ir cubriendo con el presupuesto propio del ministerio...costos por
ejemplo de insecticidas y otros materiales o tratamientos también para los pacientes...y OPS
también ha jugado un rol muy importante en todo este proceso en la parte de medicamentos y otras
gestiones, por ejemplo apoyar para que llegaran algunos expertos o conferencistas en algunas
actividades. Entonces se ha dado como...fue como todo un proceso de colaboración entre ministerio
de salud, JICA, OPS, el ministerio de educación, algunas ONGs, por ejemplo Cruz Roja hizo en un
momento, en cierto tiempo, un proyecto también...retomando los aprendizajes del país.
(8:50)...Entonces todo esto se fue fortaleciendo a nivel del ministerio de salud...esa gerencia del
programa nacional de Chagas...creo que esos son como los aspectos claves que ya movió para que
este proyecto haya tenido éxito y ya queden en el ministerio de salud...y como les comentaron los
aspectos técnicos el Ing. Romero y su equipo ellos continuan. Continuan trabajando y desarrollando
las actividades porque...el problema del Chagas es que si no se le da seguimiento, lo que se avanzó
en un año por ejemplo, puede llegar, puede regresar, puede retroceder. Entonces ellos están con ese
proceso...hay una ventaja muy importante en el país, y es que el ministerio de salud cuenta con
promotores de salud. Entonces ellos están en la comunidad, y con el proyecto también se logró
incluir el tema de Chagas, de vigilancia de Chagas en la hoja de trabajo, en el perfíl de trabajo de
los promotores. Creo que todos estos elementos también al ministerio de salud le han ayudado para
que continuen trabajando...y también se trabajó apoyando en los documentos regulatorios, por
ejemplo la norma técnica de Chagas o lineamientos técnicos para hacer el rociado y cuestiones así,
y la parte de educación. Con el proyecto se producieron, como les mencioné antes, muchos
materiales promocionales, muchos materiales educativos, y el ministerio incluso los tiene en su
página web que todas las personas pueden accesar. Entonces son como así como en términos muy
generales todo lo que se trabajó...el ministerio, ese compromiso que también lo continuan. Ahora
por ejemplo la norma, la norma de Chagas está integrada a otros temas pero siempre con miras a
poder continuar este esfuerzo. Entonces creo que también el compromiso de las personas que han
liderado el programa nacional de Chagas ha sido muy determinante. Y a su vez ellos apoyan a los
niveles locales de parte del ministerio de salud.
PR: Bueno, en primer lugar tenemos unas preguntas sobre la división del trabajo. Hemos leído que
la JICA principalmente ha apoyado en el control químico, en la encuesta y vigilancia entomológica,
y la estrategia de información, comunicación y educación. Mientras que el programa nacional ha
tenido la responsabilidad de el diagnóstico, el tratamiento, y la interrupción de la transmisión
transfusional del Chagas. Y quisiéramos saber por qué se eligió esa división del trabajo? O sea, por
qué...esas eran las áreas que iba a ayudar la JICA?
(11:50)
MA: En principio el apoyo de la cooperación japonesa va orientada a fortalecer capacidades de
recursos humanos, digamos en la parte preventiva. Entonces paralelamente, como el ministerio de
salud es el ente encargado de facilitar y proveer todos los servicios, médicos y todo, entonces creo
que esa fue como la razón, digamos, de JICA por una parte de apoyar en la cuestión de identificar
problemas, digamos, de casos de Chagas. También hubo de parte de JICA capacitaciones en el tema
de...como identificación de casos, por ejemplo en...hubo un curso en Argentina y también hubo
diplomados de entomología médica...pero es decir siempre como se ha respetado como...el rol del
ministerio de salud como tal, verdad? Ellos son los especialistas en detección y tratamiento de los
pacientes...también hubo un proceso de...como recomendar al ministerio dentro de un congreso
nacional de Chagas que occurió que se trajeron investigadores de Brasil y otros paises
sudamericanos de que los pacientes de Chagas, digamos, en su fase aguda...a todos los pacientes les
facilitan tratamiento. Pero en su fase crónica, no. Entonces según esta investigación explicaban que
aún los pacientes con fase crónica pueden mejorar su nivel de vida con esa...facilitándoles
tratamiento. Es así como, en ese caso en la próxima norma están visualizando incluir ese
tratamiento. Entonces en resumen entendería que esa división fue...quizás no lo veíamos en ese
momento así como una división, verdad? ”Yo me encargo de esto y tú del otro”. Porque resulta que
JICA por naturaleza los proyectos los desarrollamos conjuntamente con la institución...la
planificación la ejecución y todo. Entonces...y siempre se respeta por ejemplo el rol principal de la
institución contraparte en este caso.
PR: Y las áreas en las que la JICA ha participado mucho. Cómo funcionaba la planificación
estratégica? O sea entre el ministerio de salud y JICA. Quién tenía el mando?
(14:20)
MA: Bien, desde el inicio cuando se hace la...solicitud, digamos, de proyecto hay un trabajo
conjunto de planificación o de la formulación del proyecto entre el ministerio de salud o los
ministerios interesados y JICA. Entonces desde ahí comienza esa trabajo en equipo. Y luego cuando
ya el proyecto es aprobado llegan las misiones a discutir conjuntamente con los ministerios. Es
decir, no había como...quien manda más, sino es un equipo. Digamos, JICA apoya al ministerio
pero tambien sugiere de acuerdo a la experticia o experiencias que JICA tiene. Pero iba así
como...de tú a tú como discutiendo de qué era lo más conveniente para la ejecución del
proyecto...quizás hay que explicarle un poco...en los proyectos ya...es una estructura general que
JICA maneja, se conforma un equipo de coordinación conjunta y es como, digamos, la dirección
ejecutiva del proyecto y luego un equipo técnico. Entonces ese comité coordinador conjunto es el
que valida, digamos, los planes de trabajo, estrategias o...las problematicas que pueden surgir. Y es
así como se maneja como...en una coordinación o planificación estratégica pero de manera
conjunta.
PR: Y también. Las responsabilidades tenía JICA. Cómo fueron transferidas al programa nacional?
(15:52)
MA: Se transfieren desde el proceso que está en ejecución. Como la idea fundamental es transferir
el conocimiento a la contraparte nacional. Entonces desde el trabajo, el planificación...por ejemplo
desarrollar las actividades es así de manera conjunta. Es así que conjuntamente iban desarrollando
las actividades y asumiendo a su vez el, digamos, el compromiso, el rol porque cuando los
proyectos están en ejecución hay un experto coordinador que el trabaja de la mano con el ministerio
pero cuando ya termina el proyecto...hay un proceso de transferir esa responsabilidad y todo este
desarrollo de las actividades a la institución. Entonces todo esto lo llevan a cabo desde la ejecución
del proyecto...así es.
PR: Y en su opinión, en qué grado se han hecho capaces las personas del programa nacional de
realizar todas las actividades de forma independiente ahora?
(17:00)
MA: Yo creo que es muy alto el grado de capacidad. A veces la limitante que tienen como
ministerio, que se tienen a veces son cuestiones presupuestarias o de recursos humanos. Pero la
capacidad técnica...el ministerio, el equipo con el que trabajamos...es un equipo altamente
calificado.
PR: Bueno, también hemos leído que JICA ha apoyado mucho en el fortalecimiento de la
comunicación entre los diferentes niveles. El nivel central, el nivel regional y el nivel municipal.
Por ejemplo a través de los voluntarios. Pero aparte de esos voluntarios, cómo fue fortalecida la
comunicación específicamente?
(17:47)
MA: Sí...el ministerio tiene como esa estructura, verdad? El nivel central, el nivel regional y el nivel
comunitario. Entonces el trabajo se hacía tomando en cuenta los tres niveles, digamos, para la
planificación de talleres o las diferentes actividades. Siempre se hacía todo a través de el
coordinador nacional del programa pero el dependía de una gerencia, de una unidad. Entonces a
través de ellos era como el flujo de información. Pero en ese caso el experto que estaba
conduciendo el proyecto él tenía acceso a cualquier de los niveles...siempre con la comunicación
con...el coordinador del programa nacional.
PR: Y en su opinión, ese fortalecimiento de la comunicación también puede ser utilizado en cuanto
a otros temas de salud, y cómo?
(18:40)
MA: Sí. La verdad es de que...con el proyecto de Chagas se hacía esa vinculación a nivel central, a
nivel regional y nivel comunitario. En realidad el ministerio maneja esa estructura para todo eso
quehacer. Y quizás el tema importante de cómo se puede utilizar para otros programas es como se
trabaja a nivel de los promotores de salud por ejemplo y que ellos son el nivel operativo, operativo
porque ellos andan en la comunidad. Entonces como esa estructura...creo que es muy importante
para cualquier tipo de problema de salud...de Chagas o Dengue o el que va a ser...es útil, digamos,
en el sentido de manejar los diferentes niveles...diferentes niveles de gestión, por ejemplo el nivel
comunitario ve el problema día a día de la comunidad. Entonces eso ellos lo transmiten al nivel
intermedio o nivel regional...entonces ellos si ahí no tienen respuesta, lo __ (reclaman?) a nivel del
ministerio central. Entonces como que ese __ (la ven) muy oportuna para poder utilizarla para
cualquier otro tipo de problema de salud.
PR: También hemos leído que al principio, por lo menos, el manejo y análisis de datos fue realizado
por expertos japoneses, pero esa función ha sido transferida a expertos de El Salvador ahora?
(20:16)
MA: El análisis de los datos del sistema el ministerio mismo cuando inició el proyecto...el
ministerio de salud siempre ha manejado como un sistema de...donde manejan todos los indicadores
de salud. Pero el ministerio mismo ese sistema lo fue mejorando y con el proyecto lo que se hizo
fue como retroalimentar ese sistema mismo del ministerio. Entonces se entendería que en su
momento se hizo como ese proceso, digamos, de transferir pero ya es un sistema mismo que no
surgió con el proyecto, es un sistema mismo del ministerio...como propio del ministerio.
PR: Otra cosa. Ha sido la intención del programa que por ejemplo la integración de técnicos de
diferentes disciplinas y la capacitación en el manejo de datos puedan ser utilizados en cuanto a otros
temas también o en cuanto a otras enfermedades?
(21:20)
MA: Me parece que sí. El asunto es que en este caso por ejemplo se focalizaba con el tema de
Chagas pero como esa experiencia ganada por el ministerio por ejemplo...y se conversaba en las
reuniones que era como muy importante que ellos lo valoraran para implementarlo por ejemplo para
el caso de Dengue, por decirle algo, es el mismo tipo de manejo de información y también el tema
de capacitación a la comunidad...porque es..tiene como..es __ (ahí ) verdad? Decir...hay un manejo
de información pero esa información viene de los problemas de salud de la comunidad.
PR: Usted también mencionó la colaboración entre la OPS, JICA y el ministerio de salud y bueno,
quisiéramos saber cuáles han sido los mejores beneficios de esa colaboración entre 3 actores?
(22:15)
MA: Para el ministerio de salud han sido, digamos, los beneficios en el sentido por ejemplo en el
caso de OPS...bueno digamos el principal actor en todo caso era JICA, verdad? [mere principal end
OPS måske?] Porque en el operativo y OPS era un colaborador...por ejemplo en el caso de proveer
medicamentos cuestiones así y otras cuestiones técnicas...tenían también el ministerio de salud este
acompañamiento de OPS.
PR: Y cómo han sido las dinámicas entre los 3 actores? O sea cómo han hecho los convenios y todo
eso...ha habido desafíos en la colaboración?
(22:55)
MA: En el caso del ministerio de salud, con ministerio de educacón...bueno, en el caso
particularmente de OPS eran como en cuestiones puntuales...no era por ejemplo que OPS estaba
como en todo el desarrollo del proyecto, sino ellos por ejemplo en el caso del...no este es el registro
de discusiones, el documento oficial [en af dem vi har fået??] de JICA con el ministerio...o en las
evaluaciones que había, siempre había como participación, presencia de alguien de OPS pero como
un testigo (honorario), en esa categoria...la OPS no era como un implementador, digamos, del
proyecto sino que era un colaborador en cuestiones bastante puntuales al ministerio.
PR: Creo que la próxima pregunta es más para usted, Sr. Sato, quisiéramos saber qué han sido los
motivos, también del ministerio de salud pero también de la JICA, de elegir un abordaje muy
vertical...o sea un abordaje dirigido a una enfermedad específica en vez de un abordaje dirigido a
mejorar el sistema en general? Y también cuáles han sido los beneficios de ese abordaje?
(24:15)
SS: Bueno...desde mi punto de vista, el proyecto de JICA sobre el tema de Chagas no es un
proyecto de control de enfermedad transmisible, sino más bien en aspectos más...bueno, una
característica más...muy muy simbólico es algo...para apoyar el sistema de salud. En ese
sentido...bueno, no importa si es Chagas, si es Dengue u otra enfermedad. Pero lo más importante
para nosotros...bueno, obviamente para ministerio de salud es establecer un mecanismo de trabajo
de arriba-abajo, de abajo-arriba. Como usted mencionó, claramente es un tema de comunicación.
Entonces el otro tema muy, muy importante para nosotros en este proyecto fue las contrapartes del
ministerio de salud...ya tienen, ya reconoce la importancia de tomar una reacción basada en una
evidencia...entonces hasta la implementación de este proyecto los funcionarios del ministerio de
salud habían tenido trabajando pero no estaba basado en algunas evidencias, o sea datos, no?
Entonces a base de algunos datos ellos tienen que planificar la...su fumigación, verdad?, compartir
algunos medicamentos con las poblaciones...pero siempre tiene que tener datos, evidencia. Con el
apoyo de JICA ellos tomaron en cuenta la importancia de manejar ese tipo de datos y
(recrearlo/decretarlo) en su planificación. Entonces, seguramente las contrapartes de nuestro
proyecto han sido capacitados y fortalecidos en ese manejo de evidencia. Y eso no es un beneficio
para el control de Chagas, sino para todos, no? Para control de todas las enfermedades, y tal vez
aparte del control de las enfermedades, sino....bueno, control de aspectos, (carácter) aspectos de
campo de salud. Porque estamos hablando de mejoramiento del sistema de salud. Así que...nuestra
idea de trabajar en este campo con ministerio de salud es un...establecer un modelo de trabajo para
la mejora de sistema de salud en este país...estoy hablando no solamente de este país sino
Guatemala, Honduras, Nicaragua...para todos, todos. Entonces en cada país tienen su propio modelo
establecido a través de nuestro proyecto de Chagas. Entonces nuestra idea, nuestro deseo es
un...replicar esta experiencia en otras enfermedades...encontrar..._ en estos paises. Así es que es
muy, muy, nuestro proyecto fue muy, muy puntual. Pero estamos muy seguros de que eso se ha
convertido como un modelo de cómo mejorar sistema de salud.
PR: Y según su experiencia, se utiliza ese abordaje de enfasis en datos y evidencia en cuanto a otras
enfermedades también?
(28:27)
SS: Le digo francamente, no estoy seguro. No estoy seguro cómo el ministerio de salud está
utilizando esa tecnología, esa capacidad...no sé exactamente. Pero por lo menos el tema de Chagas,
aunque ya no estamos efectuando en un proyecto de cooperación...en Chagas. Ellos, como Ing.
Romero, ellos están trabajando, siguiendo la experiencia del proyecto. Así que por lo menos para
control de Chagas ellos ya están trabajando en un mecanismo ya establecido.
PR: Sí. Entendemos que eso también era uno de los objetivos más importantes que iban a seguir con
ese abordaje...también tenemos unas preguntas sobre la colaboración con otros actores...usted [MA]
mencionó que se ha colaborado con unas ONGs...y bueno, se ha colaborado con muchos actores u
organizaciones de la sociedad civil que no pertenecen al sistema de salud?
(29:50)
MA: Bueno, hubo esa colaboración con las ONGs de Fundasal que ellos se enfocan en la parte de
construcción de viviendas...
PR: Y el Fundasal, de dónde es?
MA: De acá.
PR: De acá?
MA: Sí. Y este...entonces ellos a través del proyecto de Chagas enfocaron su proyecto en eso y
utilizando materiales ya desarrollados para el proyecto. Entonces la coordinación, colaboración con
ellos era en ese sentido, en el tema de capacitación o facilitar parte de los materiales promocionales
o facilitar materiales mismos...incluyendo también el tema de capacitación a las personas para que
cuando construieran viviendas, por supuesto que esta vivienda no iba a ser tan susceptible, digamos,
la vivienda de la chinche pero ellos (llegan a) tener la mentalidad de cuidado y esa parte de
educación.
PR: Y cómo han sido seleccionados esos actores, o sea se ofrecían?
(30:51)
MA: El asunto es que como el proyecto en su caminar se dio a conocer...entonces las ONGs en ese
caso que están muy interesadas en el tema o apoyar al ministerio...se encontraron en algún momento
en territorio con el proyecto...con los expertos del proyecto.
PR: Y también han contribuido con sus propios insumos o propios recursos?
(31:12)
MA: Ellos con sus propios insumos o gestión. Por ejemplo en el caso de Fundasal..sus propios
recursos...en el caso de Cruz Roja salvadoreña implementó proyecto en la zona de oriente, en
Usulután...y ellos gestionaron fondos incluso era con fondos de Japón pero a través de __ (VIR?)
era como una gestión propia de ellos de un proyecto en el trabajo comunitario.
PR: También se ha colaborado con actores religiosos en el tema de Chagas
(31:42)
MA: En...sectores religiosos no conozco porque, digamos, nosotros a nivel de la oficina en algunas
cosas no participamos en un 100% de las actividades pero en la comunidad en general. Digamos,
ahí había personas de diferentes sectores.
PR: También nos contaron que las organizaciones religiosas se meten más en otros asuntos.
También es su experiencia que se meten más en otros temas de salud y en otros temas de las
comunidades?
(32:16)
MA: Sííí....no conozco mucho...
PR: OK. En nuestra entrevista con el Ing. Romero y la Dra. Gavidia nos enteramos de que el
programa nacional pidió a la JICA que seguiera su apoyo pero que la JICA estimó que el programa
nacional estaba listo para tomar la responsabilidad completa del programa, y quisiéramos saber
cómo se hizo esa evaluación ?
(32:50)
SS: Bueno, tal vez en eso yo tengo que responder...es que yo soy la persona que...[risas]
MA: Usted dijó que no [risas]
SS: Antes de venir aquí yo trabajaba como director de una dirección que manejaba los proyectos de
salud en Latinoamérica...incluyendo los proyectos de Chagas en Centroamérica. Entonces en los
años 2010, 2011, 2012...en esos años los paises centroamericanos ya lograron certificación
internacional...por ejemplo este eliminación de una especie aquí en El Salvador...2010, verdad?
Entonces 2011 Honduras, Nicaragua como interrupción de transmisión...entonces en ese sentido
cada proyecto de Chagas ya han logrado gran resultados...entonces no había...y eso...conocían
también los presidentes de JICA [they knew about the results in Japan] allá en Japón...entonces
ellos decían que ”por qué tenemos que seguir trabajando, [por qué] tenemos que seguir apoyando a
los paises que ya han logrado alguna meta concreta?”, verdad? Entonces por eso hemos tomado esa
decisión de ya no vamos a seguir trabajando de misma manera, de misma manera, no. Pero en ese
momento hemos tomado una decisión de enviar un experto, nuestro __ Sr. Hashimoto para
recolectar buenas prácticas de cada país en Centroamérica para que luego los ministerios de salud
de cada país tomen en cuenta esas buenas prácticas...y como un ejemplo para la mejora de sistema
de salud, no solamente de Chagas, sino también para otras enfermedades...eso fue nuestra idea...así
que hemos cambiado un poquito nuestra estrategia de apoyar a programas de Chagas...no
directamente, sino recolectar información y buenas prácticas para que tomen en cuenta cada
ministerio de salud...eso fue.
PR: Y aparte de la interrupción de la transmisión y la eliminación del Rhodnius Prolixus, había
otros indicadores que se utilizaron para evaluar los programas hace 3, 4 años?
(35:59)
SS: Si es que hablamos evaluación, evaluación de JICA, sí, nosotros manejamos siempre un marco
lógico para cualquier tipo de proyecto de cooperación...ahí tenemos...bueno, objetivos del proyecto,
resultados del proyecto...resultados esperados del proyecto, y en base de esos resultados esperados
estaba esta programa y las actividades...entonces en el nivel de los resultados y el objetivo del
proyecto tienen algunos indicadores establecidos...normalmente al inicio del proyecto de
cooperación. Obviamente, son los indicadores compartidos entre parte salvadoreña y parte japonés.
Entonces al finalizar cualquier tipo proyecto de cooperación técnica realizamos evaluación en base
a esos indicadores. Entonces en caso del proyecto de fase 2, el proyecto Chagas aquí en El
Salvador, año 2011, hicimos una evaluación final para el proyecto. Entonces, felizmente en ese
momento hemos logrado alto nivel de cumplimiento de los indicadores así que hemos definido
oficialmente que el proyecto de Chagas fase 2 aquí en El Salvador vamos a terminar como
programa. Pero siempre hay casos de que...cuando hacemos ese tipo de evaluación final y no
podemos ver (cómo se logró/con temas logró) de objetivos del proyecto (??)...siempre hay
posibilidad de prolongar un poquito el proyecto.
PR: Y en su opinión también ha habido logros que no se pueden medir, o sea logros que no se
pueden mostrar de la misma manera?
(38:17)
SS: Tal vez...mejor hablar no solamente de indicadores cuantitativos sino cualitativos...desde mi
punto de vista este proyecto, fase 2 del proyecto de Chagas nosotros enfocamos más...en segunda
fase de proyecto como fase de vigilancia donde necesitamos más participación de las
comunidades...y evaluar la participación de la comunidad es sumamente difícil, verdad? Pero...le
doy un ejemplo, cuando yo visité una unidad de salud en Ahuachapán, la parte oeste de este país en
año 2013...en ese año ya no estamos implementando un proyecto de Chagas...visité una unidad de
salud. Ahí había una pequeña caja de chinches...es una caja...cuando una persona o unos pobladores
encuentra una chinche en su casa...mejor agarrar con una bolsa y la traen a la unidad de salud,
verdad? Es un trabajo establecido dentro del proyecto...para que la unidad de salud tome en cuenta
que ya ha encontrado esa chinche. Entonces hay necesidad de visitar y hacer fumigación. Es un
mecanismo como de monitoreo establecido en este mismo proyecto de Chagas de fase 2. Y yo ví
que está funcionando ese mecanismo aunque ya no estábamos implementando ese proyecto en año
2013...entonces es un ejemplo...y tal vez es una muestra de que cada comunidad está mostrando su
interés de participar.
PR: Perfecto. Nosotros también hicimos una visita a una unidad de salud en San Pablo Tacachico en
La Libertad, y allá nos enteramos de que JICA ha apoyado mucho en las actividades de promoción
y que ha sido un apoyo muy importante para ellos. Pero sin embargo, nos contaron que ahora hay
menos recursos para las actividades de promoción y también para los materiales, y también que se
podría utilizar más recursos ahora, y en su opinión cómo se puede mejorar esa situación?
(41:45)
[risas]
MA: (se le doy la palabra)
[risa]
SS: Tal vez el...no es asunto directamente causado por...por falta de iniciativa o motivación de los
recursos humanos del ministerio de salud, sino que a veces...en cuanto a control de vectores siempre
ellos tienen que poner la prioridad el ministerio de salud. Por ejemplo si aumenta casos de Dengue,
la persona tiene que trabajar fuertemente en ese tema, verdad? Y obviamente ellos no tienen
suficientes recursos humanos para (tratar) al mismo momento Dengue, Chagas y otras
enfermedades. Entonces siempre hay...siempre ellos tienen que (poner) el apoyo en su trabajo (??)
Así que sabemos muy bien que control de Dengue y otras enfermedades tiene más presupuesto, más
recursos que lo de Chagas. Por eso siempre está denominado como una
enfermedad...desatendida...así que tal vez ellos mismos pueden mejorar esa situación
porque...como, repito, que ya ellos tienen bastante conocimiento, están ya capacitados en trabajar en
base a evidencia...entonces si es que aumenta unos casos de Chagas, ellos pueden presentar esos
datos para lograr su recurso propio para fortalecer su trabajo en cuanto a Chagas...eso es lo que
estamos esperando...y bueno, es muy fácil que nosotros hablemos con ministerio de salud, pidiendo
que aumenten el presupuesto en cuanto a Chagas pero eso no es...no funciona...no funciona
siempre. Así que tal vez ellos mejor...para ellos sería mejor utilizar su capacidad que se ha
fortalecido en el proyecto.
PR: Un poco relacionado a esto...según su experiencia cómo está visto el tema de Chagas entre los
otros temas de salud como el Dengue o la Malaria u otros problemas de salud?
(44:44)
MA: El tema de Chagas...bueno el tema de Dengue siempre ha tenido alta prioridad porque el
Dengue afecta a la población en general, no importando el estrato social. No así el tema de Chagas.
Sin embargo, con el proyecto se logró avanzar y visibilizar, digamos, la necesidad de poner los ojos
o recursos en el tema de Chagas...y ahí lo que benefició, como le mencionaba antes, era por fortuna
la Ministra era persona conocedora del tema, y había compromiso, digamos, en términos
humanitarios con las personas de escasos recursos y que además de eso...de esta situación de
dificultad en términos económicos estaban adoleciendo del problema de Chagas. Entonces, sí hubo
reconocimiento pero quizás ver sus otras enfermedades creo que no es como la alta prioridad...ver
su Dengue o algunas otras como la Chikungunya que ahora es uno de las enfermedades que han
aparecido.
PR: Otra cosa...en la correspondencia entre usted, Sr. Sato y el Sr. Hashimoto y nosotros mencionó
que es difícil encontrar lugares seguros para los voluntarios de JICA para trabajar y para quedarse
por la situación de la delincuencia en el país...y quisiéramos saber si ha sido afectado el programa
de Chagas por la inseguridad del país y cómo?
(46:25)
SS: Normalmente nuestros voluntarios tienen que trabajar en el campo, verdad? Entonces me estoy
refiriendo con...viviendo en una familia salvadoreña. Es normal para nuestros voluntarios...entonces
el tema de seguridad es sumamente importante para envío de los voluntarios...pero por ejemplo en
nuestro reglamento de seguridad de nuestra oficina...más de 30 municipios no son lugares
adecuados para nuestros voluntarios trabajar...así que, bueno, están incluidos algunos lugares que ya
han sido como...lugares de objeto de proyectos de Chagas pero por el tema de seguridad no
podemos enviar nuestros voluntarios...pero quizás...tenemos una voluntaria que está trabajando el
tema de Chagas en Santa Ana...ahí sí y no tenemos esos problemas de seguridad...pero el...cada año
tenemos que revisar nuestro reglamento de seguridad en base a las realidades del país...es una
situación muy lamentable para nosotros pero la seguridad para nuestros voluntarios es lo más
importante.
PR: Ahora quisiéramos saber un poco más sobre los beneficios y los logros del programa, y en su
opinión, cuáles han sido, aparte del fortalecimiento de la comunicación y la utilización de datos y
eso, cuáles han sido los mejores beneficios del involucramiento de JICA en el control de Chagas?
(48:49)
MA: Yo creo que los mayores beneficios están en...han sido en la población, digamos, en la
población que no estaba afectada y que a través de los procesos de educación, por ejemplo con los
estudiantes o con la comunidad...ya no fueron afectados por ejemplo...porque incluso con el
proyecto muchos médicos no conocían sobre el Chagas...es decir fue un proceso también de
educación también para los médicos...creo que por una parte, fue, digamos, la parte de promoción y
educación...fue uno de los beneficios importantes para la población.
PR: Y también piensan que el sistema de salud ha sido fortalecido en otros temas aparte también de
la comunicación y ese abordaje?
(49:41)
MA: Yo creo que sí, en la parte de...bueno, dentro del ministerio hay una unidad que se llama
Promoción de la Salud, y Promoción de la Salud es para diferentes temáticas...de ahí ellos, creo que
han aprendido mucho el tema de...y la metodología de trabajo con el programa de Chagas. Por
ejemplo esa parte educativa con la comunidad y esa participación comunitaria, creo que también
por ahí...
PR: Y en su opinión, cuáles son los mayores desafíos de la prevención de Chagas ahora?
(50:15)
MA: Ahora no le hemos dado seguimiento tan cercano [so she doesn’t know that well] pero...los
desafíos en términos presupuestarios es uno que...como le mencionaba en todo [budget is a
challenge in everything]...pero creo que los desafíos son, y fueron también durante el proyecto la
alza de los casos principalmente de Dengue...entonces por ejemplo incluso con el proyecto cuando
estábamos, aunque tuviesemos talleres pero si el Dengue se disparaba que es en cada año que ocurre
lo mismo, toda actividad en otros temas se ve obstaculizado...creo que eso puede ser uno de los
desafíos ...el __ (latendero?) dedicarse, atender a otras epidemias que surgen en el camino, digamos,
en los diferentes periodos en el año, creo que eso estaría...y creo que sería uno de los
desafíos...seguramente tendrá más.
PR: Y según su conocimiento, han surgido nuevos desafíos desde que JICA terminó su parte del
programa...para el programa nacional?
(51:20)
MA: Yo creo que, digamos, en términos de monitoreo de alguna manera con el proyecto se le daba
como seguimiento y evaluaciones periodo de cada 6 meses. Ahora ellos lo hacen pero no así como
con ese nivel de periodicidad con ese nivel de seguimiento porque había un experto...yo creo que
eso quizás ha disminuido, aunque ellos dan su seguimiento pero en general para otras temáticas.
PR: Otra pregunta para usted, Sr. Sato, usted viene de un lugar muy lejos [lejano] y también
trabajaba en otros asuntos acá en Latinoamérica. Ha visto condiciones del trabajo acá que sean
específicos de Centroamérica y de El Salvador?
(52:18)
SS: Antes yo trabajé en oficina de JICA en Bolivia de 2002 a 2006...bueno, comparando esa
experiencia en Bolivia...los salvadoreños no son tan latinoamericanos [risas]...ellos...muy exigentes
en su trabajo y trabajadores...entonces me parece muy...a veces demasiado serios en su
trabajo...pero...tal vez es una caraterística muy representativa de este país y la gente también...y eso
nos facilita bastante...no solamente en el proyecto de Chagas, sino para cualquier proyecto de
cooperación técnica...siempre tenemos una contraparte muy entusiasmada de trabajar con
nosotros...muy comprometidos. Entonces, sí, eso facilita bastante.
PR: Y de qué manera ha sido necesario para JICA y para usted tener una mente abierta en cuanto a
otras formas de trabajar o no ha sido tan necesario? O sea, cómo ha sido necesario tener una mente
abierta a otras maneras de trabajo?
(54:07)
SS: [risa] hasta ahora no pensaba tanto en ese tema [risa]...pero...cómo le digo?...en inglés dicen __
(divulsion/divorcion?)..eso tal vez es una palabra muy representativa de esta población...y me estoy
refiriendo no solamente a...como se llama...enfocar su trabajo, sino con sus colegas siempre trabajo
fuerte, trabajo fuertemente...así que eso tiene un impacto muy grande cuando nosotros o los
extranjeros trabajamos con los salvadoreños.
PR: Y cómo ha utilizado sus experiencias de Guatemala de la Oncocercosis y las investigaciones de
enfermedades tropicales acá en el Salvador...la JICA?
(55:20)
SS: O sea, utilizar las experiencias de aquí en El Salvador a otros paises o..?
PP: También...pero también las experiencias que tenían desde los programas de los años 70, 80, 90?
(55:38)
SS: En cuanto a Chagas, como ustedes saben bien, empezamos nuestra cooperación en
Guatemala...y ahí..ese proyecto fue muy...no tan tradicional...es que, repito, este proyecto de
cooperación técnica en cuanto a Chagas no es un proyecto de control de enfermedad transmisible,
sino es un proyecto para establecer...para mejora de sistema de salud...entonces en ese primer
proyecto en Guatemala no tenían experto como médico...sólo tenía un experto de coordinación
junto con el grupo de los voluntarios que trabaja en el campo...ellos tampoco no están
especializados en medicina...pero ellos trabajaron como si fuera desarrollo comunitario...eso fue
una característica del primer proyecto de control de Chagas en Guatemala, y esa característica de
alguna manera ya ha sido aplicada en cada proyecto en El Salvador, en Honduras, en
Nicaragua...creo que ningún proyecto tiene experto de médico...siempre es un experto pero en
coordinación o algunas...como se llama...investigación social...ese tipo. Así que...tal vez una
experiencia, nuestra experiencia en Guatemala, eso...hemos replicado en los proyectos, todos los
proyectos de Chagas en Centroamérica.
PR: Y cuáles son las actividades que se realizan ahora por la JICA aquí en El Salvador?
SS: En cuanto a Chagas?
PR: No, en cuanto a otros temas...
(58:03)
SS: Sí, tenemos...bueno, estamos hablando de nivel de proyecto para ahora...pero bueno, arriba de
estos proyectos...tenemos unos programas de cooperación. Por ahora, tenemos 2 programas de
cooperación _ (curiorisal?) aquí en este país. Uno es un programa de desarrollo de zona oriental...es
un desarrollo territorial, me estoy refiriendo a 4 departamentos de este país como Morazán, La
Unión, San Miguel y Usulután, 4 departamentos. Y otro programa es una gestión de riesgo como
que este país, no solamente este país, pero varios paises de Centroamérica tienen la dificultad, el
problema de gestión de riesgo...como prevención de desastres naturales...y como ustedes saben
bien, que nuestro país, Japón, también es un país muy vulnerable ante cualquier fenómeno de
desastres naturales...entonces compartiendo nuestra experiencia, estamos apoyando a El Salvador y
otros paises de Centroamérica...son los 2 programas... __ __
...Peter, yo tengo otra reunión que comienza a las 3...entonces los voy a dejar aquí...está bien?
PR: Sí, de hecho sólo tenemos unas formalidades que querríamos mencionar...o sea, quisiéramos
saber si hay algo importante sobre lo que no hemos preguntado, en su opinión?
(1:00:20)
MA: Yo creo que en términos generales está cubierto, digamos, como los más grandes líneas de
trabajo, los __ (grificios), los actores y coordinación...
PR: Entonces sólo explicar una última cosa que, no creo que lo mencioné [mencionara], que no
tenemos la intención de publicar esa tésis, pero si en el futuro tenemos la oportunidad de hacerlo,
vamos a pedirles su consentimiento para publicarlo, y otra cosa también que ustedes pueden quedar
anónimos en la investigación si lo desean...y también si lo desean, estamos muy dispuestos a
compartir nuestros datos con ustedes y a mandar el proyecto final para que ustedes también puedan
leerlo cuando tengan el tiempo
SS: Sí tengo bastante interés...[risa]
PR: Y al final sólo queremos agradecerle mucho su tiempo. Ha sido sumamente informativo para
nosotros y nos ayuda muchísimo a realizar nuestra investigación y...no alegra mucho que hayan
tomado el tiempo para hablar con nosotros y estamos muy agradecidos..
(1:01:50)
Interview with Dr. Victor Mejía, Adviser - PAHO, 9th of December, 2015,
... = pause in the speech
__= can’t hear what is being said
[ ] = when something is understood but not being said
( ) = If I am guessing a bit about what is being said from the context fx.
directive/guideline/norm = la Norma Técnica 
[First, introduction, and we ask if it is OK to record]
PR: Well, first of all we would like to thank you a lot for your time and your participation, which is
very important to us because we have already read many documents and reports but it helps us a lot
to talk to the persons who are actually involved in the programs. And well, to begin with, we have
read that PAHO mainly has provided technical support through subregional meetings, seminars, and
evaluation missions. And in your opinion, how have these meetings between the different actors
been useful?
VM: Normally, in the plan...PAHO’s planning is done biannually, every 2 years, and the planning is
always done in line with a document, which is a base(line) document which is negotiated with the
ministries of health at the beginning of the biennium, the biennium which encompasses 2 years.
And this base(line) document is where PAHO’s cooperation is framed/outlined for working and
evaluating every 6 months. In this case, if it is 2 years, evaluations are made 4 times a year about all
the activities which PAHO proposes in relation to the necessities of the ministry. In the particular
theme of Chagas disease...as you know Chagas disease is one of the neglected disease...and
therefore in this country, as in the majority of countries in Central America, the theme of Chagas
disease is an institutional theme of the Ministry of Health...however, the financial and technical
support has generally been rather limited...in the sense that, as you mentioned, that JICA, PAHO,
and other institutions such as GTZ1 or GIZ2 at present, which is the German Technical Cooperation
Agency which at some point was interested in providing support for Chagas disease. We as PAHO,
right hand of the WHO let’s say, have strategic regional plans on the websites that you have
checked, in which the institutional work is basically framed/outlined, which is principally aimed at
the elimination, in the case of this country the control and elimination...of the principal vectors.
Both the Rhodnius prolixus and the Triatoma dimidiata...in this case, in our country basically the
major quantity of vectors are the Triatoma dimidiata...in 2010 the country was declared free of the
Rhodnius prolixus, and so far the entomological checkup, which the Ministry of Health has done,
has not found it. Yes, a new vector has been found, which is not really new but it was thought to
have disappeared, the Triatoma Ryckmani...principally in the zones of the east...Usulután, San
Miguel...it has been identified in the zones of the east...but returning to the point...so our
fundamental work consists in providing technical support, and maybe not as much the financial
support which, as I mentioned...the financial support which is normally there for these diseases is
not a lot...the country is doing a good job in the theme of control, and apart from this there is the
advantage that the poison, the Deltamethrin, or the poison which is applied in Dengue control, for
the control of Anopheles in the case of Malaria, is a poison which also has an important effect
against the Triatoma...so in a way, the fact that we, the country, the ministry of health, apply this
poison in the houses, in the spraying, which they do in a permanent manner...all these control and
invervention activities, which they are doing, have given good results indirectly because the interest
is to avoid the __ [a type of vector mosquito for Dengue, I think] or the anopheles __, but indirectly
the population of triatomas has also been controlled...
but nevertheless, even though the Ministry of Health has done a very important job with the anti
vectorial activities and also with the control in the diagnosis of acute cases and the detection of
chronic cases...we have alse seen the necessity that they focus their interventions principally on the
border zones with the departments...sorry, the country of Guatemala. Why? Because...it appears
that...we have seen an important burden of migrant persons who come from other countries [who
have the disease], but apart from that, the algorithms of detection and diagnosis have not been
improved until now, in the case of Guatemala for the detection of acute patients...2 years ago a
cooperative project was done between the governments of Guatemala and El Salvador, the
1
Agencia Alemana de Cooperación Técnica – German Technical Cooperation Agency – Deutsche Gesellschaft für
Technische Zusammenarbeit.
2
Deutsche Gesellschaft für Internationale Zusammenarbeit
Ministries of Health of Guatemala and El Salvador, PAHO in Guatemala and El Salvador, which
practically intervened in the border zones of Ahuachapán and Santa Ana...fundamentally with the
exchange of information, with standardization of the algorithms of laboratory diagnosis, and with
the clinical management of the acute patients, and in that case the human resources were
strengthened a lot, the diagnostic laboratory capacity, but apart from that theme the surveillance was
a fundamental axis...we had very good results so that in the case of Guatemala they have been
diagnosing the acute cases in a more timely manner as they before this project had a bigger quantity
of chronic cases, and logically, in order to reach the chronic phase of Chagas disease, a case has to
have passed through the acute stage. And the detail, or the criteria is to identify the acute cases,
principally those cases where the signs or symptoms are few...because now we do not see many
cases with Romaña’s sign, Ptosis...people generally search for an alternative treatment, selfmedicating or looking for an option of alternative medicine such as a medicine man...or within
their own family the grandmother or grandfather give medicines which are not for this...and this
does that the acute stage tends to hide itself...as you know, it can last 2 or 3 weeks, and it goes on to
a subclinical phase and later to the chronic stage...and a lot of those children or adults will probably
never know that they had Chagas disease...not until there are already cardiac problems...in our
country it is principally cardiologic problems...cardiac hypertrophy...it is when they are already in
an advanced chronic stage that they are diagnosed with chronic Chagas disease...however, another
important detail is that...the screening which is done in blood banks is for a 100% of the blood...we
have seen that this is where it has been identified that we have a rather high percentage of chronic
Chagas disease...I do not have the facts at hand now for 2015...but nevertheless we have seen that
[the rate of] chronic Chagas disease is 2 or 3 times higher than HIV or Hepatitis B...which means
that if it is diagnosed in the chronic stage, it is not diagnosed in the acute stage, and much less
treatment is being given in the acute stage. The theme of diagnosing the acute cases also has to do
with the availability of the medicines...because if you diagnose it in the acute phase – one: the
health system has the responsibility and the obligation of giving its medicines...
PR: To all the cases...
VM: To all the cases, according to the directive/guideline/norm. But the problem is that the
Benznidazole or Nifurtimox...the thing is that there is a problem with these medicines...that locally
there does not exists commercial houses/firms that offers them because the number of cases is so
small that each year there is an average of 5, 6 acute cases, and therefore it is not a good business
for the firms to offer such a small quantity of treatment.
PR: But is that because all the cases are not detected?
VM: We believe that there is a underreporting...or rather than underreporting, maybe an
underdiagnosis...an underdiagnosis because if the prevalence of chronic Chagas disease is 2 or 3
times higher than for HIV, and the number of acute cases which are being diagnosed is so small,
like 5 or 6 per year, it means that there is an important percentage in the acute stage which goes
unobserved or misdiagnosed, or it is simply because the people do not consult [a doctor]...
PR: Is it also because of the fact that the disease is often asymptomatic?
VM: Yes, exactly. In fact, the doctor who, let’s say, is in charge of PAHO at regional level in the
theme of Chagas, Dr. Salvatella, and he is in Uruguay, commented at a conference that the
experience, he has had over many years...they have seen that only 20 or 30 % of the cases of acute
Chagas present Romaña’s sign...but nevertheless, in our case the interesting thing is that almost 90
to 95% of the acute cases have presented Romaña’s sign...but people do consult [a doctor] because
of that Romaña’s sign...but nevertheless we do not know which percentage passes to an
asymptomatic or simply subclinical stage, or if the manifestations are so mild that the people feel
better with an Acetaminophen and do not look for [treatment]...because of this...and we have seen it
with Ing. Romero...we have a pending debt with the people who have chronic Chagas disease.
Principally because the directive/guideline/norm now says that those persons, a 100% of the cases
should, under certain conditions, receive treatment in the chronic phase, according to the evaluation
which is done by clinic, a cardiologist, or the internist.
There is a study, I don’t have it, it is very interesting, I think that Ing. Romero has it, where the
national hospital Rosales, which is the National Hospital of Referral at the third level in the
country...2 or 3 years ago, maybe a bit more...did a study where they showed that 60% of the
patients with chronic Chagas disease ended up being seronegative at the moment of doing the
ELISA control after their treatment of 60 to 90 days. So that set the pace for thinking that yes, the
medicine, the Nifurtimox in this case could be an important therapeutic option in the case of the
patients with chronic Chagas disease. But only for those patients where the ELISA for Chagas
continues to be positive...remembering that the cardiologic problems of hypertrophy or bundle
branch block, those cannot be...those are not reversible...but it [the treatment of chronic patients
with medicine] is more to maintain the serological state because once the heart is damaged, there is
no way back, except if it is in a rather early stage...there are some medicines for the diagnosis of
hypertrophy which the cardiologoist use so that they help the heart, and the person’s quality of life
tends to improve...but if there is heart failure or a rather advanced hypertrophy, the person is
normally only with the medicines to supplement diuretics, Furosemides or others...however, as I
mentioned, those studies have been very important guidelines to be able to include the treatment of
chronic patients.
PR: Perfect. And you mentioned the technical support, but in what specifically....
VM: Yes, there are 4 things which are done, basically. First, with the Department of Infectious
Diseases and the Department of Environmental Sanitation, which is where Ing. Romero is, it is with
them that the training is coordinated for the clinical diagnosis, for the theme of entomological
surveillance, and also for the theme of...the serological investigations...it has been 2 or 3 years since
JICA did the last serological investigation...we have not supported in the serological investigations
for the last 3 years, just one study, which I mentioned, which was done 2 years ago in the border
zone...and the other theme is that we have also supported in...when there have been regional
meeting of the IPCAM, which is the initiative in the elimination of Chagas in Central America, we
have also financed that persons from El Salvador’s Ministry of Health have gone to these meeting,
and we have also provided technical support in order to...that the national program has had its
directive/guideline/norm of Chagas disease updated...for this new directive/guideline/norm which is
still in the review process...there is a request...the Ministry of Health was asked to include all the
vector-borne diseases in a single document. There is Malaria, there is Leishmaniases, there is
Chagas disease in a single document. But it is still in review, and there is only the previous
version...as long as it is not approved, the previous directive/guideline/norm is still being used. So
those elementes are where PAHO principally provides support
Often there is also support when the Ministry of Health has not been able to buy the ELISA for
Chagas within its normal programming...the Chagatek is the one that the firms normally have
so...and if there is available funds, the National Laboratory of Referral is supported in the
serological work, in this case Lic. (Marta Eliza) Fernández who does the parasitological work and
there is also another Lic., I don’t remember her name...[they are supported] at the time of the
confirmation of the...cases of chronic Chagas disease principally. So we buy reagent for them
too...and well, the thing I already mentioned, the training which is done with the personnel when
they are sent abroad...we have also provided support when there has been a need to reproduce
educational material for Chagas disease...however, we know that the financing is not sufficient but
with the little there is, the Ministry of Health has been supported.
PR: And the evaluation missions which have been done, what are the indicators that are made to
evaluate the programs?
VM: Yes. Normally the evaluation which is done with Chagas disease, the indicators are principally
entomological, right? because the...you already mentioned it...the Chagas program is a very vertical
program. Ing. Romero, he is number one, and his focus is entomology, right?
Entomology...however, when they are evaluated, with the 5 regions of health that there are in the
country, all the indicators which are done are entomological but there are also indicators of
surveillance...when they have to see the percentages of detection of cases, follow-up, recovery...all
those indicators are in the evaluations...last year...I think...the last evaluation...because as we have
not been able to finance...this year we could not finance an evaluation, last year we could...all these
evaluations are done, and Ing. Romero has them...the majority of places or persons from all the
regions, which are presented, are very positively evaluated...but our criticism or comment to the
vector program always is that even though they comply with their indicators of detection, of
diagnosis, of entomology, of house checks, of checking if the chinches are [sero]positive in their
excrements...even though they are very positively evaluated with their numerator and denominator,
we keep on having chronic Chagas disease, we keep on having acute cases...therefore we wanted,
we want them to improve, or evaluate, or reconsider if those indicators truly are responding to the
necessities there are...because, to give an example, en the western zone there are 3 departments:
Sonsonate, Santa Ana, and Ahuachapán...those are the 3 departments with the largest number of
cases of Chagas disease...they are always very positively evaluated...but if they are very positively
evaluated, there should not be cases of Chagas disease, neither chronic nor acute. So we come back
to the same theme, so it could be that the information that they are giving or providing is not that
real as it is visualized...therefore we also need another thing, which we have commented to Ing.
Romero, that a closer monitoring, supervision is needed before the evaluation so that the indicators,
which they present in the evaluations, really reflect the work or the reality of the
communities...because if not, you have indicators – ”very well, a 100%, very well, everything
good”, but the cases in the communities which often have not been diagnosed or detected [are left
out – he does not say this explicitly but it is fairly obvious]...
A very important work that was done with JICA was the community entomological surveillance
where the people captured the chinches, they put them in a small bag, and they went to leave them
at the closest health center. This project is still being done, it is still being sustained, it is still being
implemented but we...the last time we spoke to him it was necessary to evaluate if it was really
giving results...because we have also detected that often the people do it...they capture chinches in
the house, put them in a box, they go to the community family health center, but from here they do
not send them [the chinches] to the next level where the diagnosis is being done, which is at the
level of the SIBASI, the basic systems of integral health...so if he, the person, takes the time to
capture the chinche, to put it [in a bag], to go to the community family health center to leave it, why
does the community family health center not send it to the SIBASI, to where it belongs, in time and
while the chinches are alive?
PR: There is no reason if the don’t do it...? [send the chinches forward in the system]
VM: If they don’t do it [send the captured chinches on], it stays here. It does not happen in all the
cases but we have seen cases where persons, who have been sick or have been diagnosed with acute
Chagas, have done this with the chinches but the information did not arrive [to the central level], so
here in this step there is a...there is a limitation...because the other thing that we have seen, as this
[procedure] is not perfected, is that often the manager of the health unit or the doctor who is there –
they are often in their social year. So they are doctors who still have not graduated, who are in their
eighth year, the social year, and at times they do not consider it important to follow the chain which
they are supposed to because of a lack of expertise, of knowledge. So we have identified and
commented that limitation...it has been tried to correct it...but nevertheless, again, if all this really
functions, why do we keep on having [new] cases of chronic Chagas? Also therefore...another of
the things that we have commented to Ing. Romero is the necessity of elaborating online courses or
training courses, some kind of mechanism to...so that not only the entomologists are diagnosing,
and the microscopists who see the blood film and identify the parasite, but so that also the doctors
who are in the health establishments get up to date on the disease...because that can...I know cases
from 2 years ago, which I mentioned, when we did the project with Guatemala in which we were in
the field seeing acute Chagas cases, and cases that were already in the chronic stage which had been
acute. And when they were acute, the children of 7, 8, 9 years...when their parents brought them to
the health unit, the doctor saw them and attended them and ended up giving them some eye drops
thinking that it was a bacterial infection...so he never thought that it could be another thing, and in
that moment he could easily have sent a blood film...or have taken blood for Strout’s concentration
method to see the diagnosis and give the opportune treatment...another thing that we have seen is
that more follow-up is needed with the acute cases who receive treatment because in these
cases...you know, the treatment of an acute case of Chagas disease is given according to
weight...and often we have seen cases which have been...mismanaged...so the doctor comes,
prescribes the medicine and gives it to the patient...”here is your vial of medicine, your dosis for 90
days”, and this persons goes to his house. But the person thinks, as no one is supervising, that it is
left to his discretion, to his criteria...he is told to take the medicine but when the person gets rid of
[the symptoms], he thinks that he is already cured...so an important educational component is also
lacking...right? Because sometimes the health establishment is so saturated that the educational part
[of the treatment] is not given.
PR: More follow-up from the doctor is needed?
VM: The two things...the educational part...to explain to the person that even though he gets rid of
[the symptoms], it does not mean that he is already cured...until further treated...the follow-up by
the health promoter...this country is very successful, the Ministry of Health with programs such as
HIV, such as Tuberculosis...such as Malaria with which we are in the stage of elimination...but
nevertheless we have been detained in Chagas...as I mentioned, the evaluations can be very positive
but as we have detected those limitations, those difficulties, we also need to have more follow-up
from the doctor, from the health promoter, from the epidemiologists, even from the community,
right? Because, I repeat, if the person takes the medicine with him, and he or her feels healthy, he
feels fine, then he does not see the necessity to take the medicine...with the work that we did in
2012 with Guatemala we saw that there were persons who...despite that Chagas disease had been
explained to them at an opportune moment, they did not complete their treatment schedule...maybe
they still had 20, 30 tablets left of a schedule of 90 days...between 60 and 90 days depending on the
medicine...so as you already mentioned, more follow-up of the cases is needed...and another
interesting thing is that this country can do it, and it can do it because the number of cases is pretty
small. Other countries of Central America where the number of cases of Chagas disease is bigger,
cannot do it because of the certain logistics that they have. The case of Guatemala and its jungle
zones or Honduras and the big areas that they have to cross to visit the homes...this [El Salvador] is
a small country, we have 20.000 square kilometres...you are in the west, in 3 hours you arrive in the
east and you already crossed the whole country...so those things or those situations are those
that...at one point we commented it to Ing. Romero, he is conscious that it is necessary to improve
various things...
and the idea of technical assistance is to keep on...to never stop supporting the training of the
personnel in the theme of surveillance, in the strengthening of human resources, and even when it is
possible in the strengthening with equipment such as microscopes, where they have an important
limitation at times...and the diagnosis which is pretty important. Likewise, as I already mentioned,
we normally administer the purchasing and/or the donation of medicine through PAHO...because
PAHO works with a fund which is called the Strategic Fund or the Revolving Fund which consists
in that joint purchases are done for various countries of a medicine which is normally not available
in the country. For example, now the treatment for Malaria, for Swamp Fever, we don’t have it
available but we are administering the donacion of medicine, and we are hoping that it arrives in
January. The same story with Chagas disease, the same story with Leishmaniases in which the __
[he mentions a name of a medicine for Leishmaniases, I think]...whichever of the medicines that are
used, which are not available here in the country.
PR: Actually, we were thinking, why has it been decided to use Nifurtimox instead of
Benznidazole?
VM: All of the decision about which is used and which is not came from an accord in which
infectologists, infectious disease physicians, and internists were summoned, and the properties of
the medicine were evaluated, and therefore the use of Benznidazole and Nifurtimox has been put in
the national directive/guideline/norm...that is the two medicines are in the scheme...however, for us
it is easier to obtain the Nifurtimox than the Benznidazole, and there is another very important
theme which is the limitation that we have that we cannot get pediatric medicines, even though we
have made the effort. In the case of children it is necessary to crush the tablet in order to give them
the adequate dose. We have not been able to overcome this situation. And the medicine is bitter,
which is why it is almost required that the child has the tolerance at the moment of ingesting it,
right? For the parents...if the children sometimes...often it is not the parents who take care of these
children, it is the grandparents, and the grandparents [sometimes] do not get involved and often they
do not give the treatment because the children are doing this [he is gesturing: ”make a fuss”] and
they fight being given the medicine etc. So, as I mentioned, these are the things that led to this
accord of putting the medicine in the directive/guideline/norm...however, in the
directive/guideline/norm...there has been an important delay because it has been in review since the
year 2012...so from 2012, 2013, 2014 and we are entering 2016, and they never approved the
directive/guideline/norm inside the Ministry of Health. So now when they will approve it, and if it
is that it comes out for the year of 2016, it is going to be a directive/guideline/norm that still needs
to be reviewed again because it has already been delayed for 4 years.
PR: But you [PAHO] did not approve it, or?
VM: No, the thing is that...we give technical support in revising it but inside the Ministry of Health
there is a department which is called the Regulations Department in which they review all the
documents inside the Ministry of Health, and there with their team of lawyers, with their
technicians they say...they review the document to see if it is necessary to improve it, or if it
proceeds. Once the Regulations Department has reviewed the document, they send it to the Vice
Minister of Health, the Vice Minister of Health approves it, passes it on to the Minister of Health,
and the Minister of Health makes a...something which is called a ministerial resolution. The
ministerial resolution is what says ”based on her technical and constitutional faculties, the Minister
of Health approves that the directive/guideline/norm can be used” in a certain period. But to get
there, it is in regulation, and regulation has been...an important heel in which the documents often
are for up to 2 or 3 years, and never come out from there, and when they come out, they come out
delayed as in the case of the directive/guideline/norm. Also given this, we went...with our
representative, Dr. (Carlos Garzón), we went with him to see the Minister of Health, and they have
made some changes inside [the Ministry of Health] so that the the one who was the boss of the
Regulations Department was removed and also some other technicians, and now we think that this
is going to help in expediting this whole process. But returning to the point, we make suggestions,
we make recommendations, and it is up to the country to decide if they will adapt and adopt the
guidelines which come from the WHO.
PR: They [Ministry of Health] has not approved it...and it is the directive/guideline/norm...
VM: The directive/guideline/norm of Chagas disease, yes. But there is the problem, which I
mentioned, that now...from 2012 they asked that all the neglected diseases be put in a single
document. So there is Malaria, Leishmaniases, Chagas, principally these...and Rabies, I think. So as
it is a single document, if they do not approve that document, we do not have a
directive/guideline/norm in force...unless that...until it is approved and signed by the Minister of
Health, the document in force is the previous one, right? The only one which is approved...which is
from 2011 if I am correct. So from 2011 to 2015 we have almost 14 years of delay...sorry,
2011...no, we have 4 years of delay. So...this [the new document] needs to come out...everyone is
conscious that it is a necessity, everyone. But we believe that now, with the change of authorities in
the Regulations Department, we are going to have a directive/guideline/norm ready next year.
PR: Perfect. Well, you mentioned the geographic differences between the Central American
countries, and you also mentioned the successess with other diseases here in El Salvador. But in
your opinion, at what level is the capacity to control Chagas here in El Salvador compared to the
other countries? Is it better here, or?
VM: The thing is that the country...we have in a way supported the Ministry of Health in improving
its surveillance system, the detection of cases, the training etc. And this has done that the country
identifies, detect or diagnoses acute cases of Chagas. If you revise the agreements of IPCAM which
is this initiative...for the elimination of Rhodnius prolixus and...T. dimidiata...of the countries of
Central America El Salvador is practically the country which identifies the most acute cases
PR: But that is also because of the capacity to detect them, right?
VM: Because in a way they [in El Salvador] are trained, they have the knowledge, and practically
the theme of Chagas disease in the countries...in the border departments [of El Salvador] it is a
mandatory theme of surveillance...it is mandatory in the whole country but more in those
departments where there are a larger number of cases. So that has led to, and also because of the
training that has been done, that the persons can be up to date in the knowledge of diagnosing
Chagas...we are always detecting more cases. So the rest of the countries...I...I know the situation of
most of them...but the case of Guatemala, as I already mentioned, 2 years ago this project with them
was done, and now they are diagnosing acute Chagas disease. They were always diagnosing but
now they are diagnosing more. Because they did not use Strout’s concentration method for the
diagnosis of the acute phase. They were only doing the blood film, the microscope, and it took them
3, 4 months to send an ELISA. They were not using the diagnosis, Strout’s concentration method as
a part of the diagnosis...as a part of the examinations for the acute diagnosis. With the training, they
went from here, from the Ministry of Health, they trained the technicians [in Guatemala], and now
they are noting. Because, you know, often if there is a parasitic drop or of the parasite in the blood,
it can happen that the blood film and the observation do not diagnose it. But yes, Strout’s
concentration method helps to identify the parasites in the blood in [the case of] a parasitic drop.
PR: How do you spell that, Strout?
VM: Let me...S – T – R – O – U – T. Strout’s concentration method. Just a second
[He answers his phone for a few seconds].
PR: Another thing. In your opinion, what have been the biggest benefits of the collaboration
between JICA, the Ministry of Health, and PAHO? That is, how have the dynamics been, and what
have been the biggest benefits?
VM: Well, we as PAHO, we have guidelines from Geneva from the WHO about complying with
this plan, as I mentioned, the regional plan of Chagas elimination...the benefit for us has been that
the country has implemented many of these strategies. They are not new, they are the same
strategies which are being followed this year. However, there has been put more and more emphasis
on the management and diagnosis of acute cases and the follow-up of chronic Chagas disease. The
benefit that the Ministry of Health has had is that they have been doing the diagnosis of the cases
even with the limitations that they have...the follow-up of the chronic cases even with the
limitations that they have...but they have realized the necessity of for example screening a 100% of
the blood donors. Before, 10-15 years ago, this was not done. Only, a certain percentage of all the
blood stock was selected randomly to do the ELISA screening for Chagas. But the ELISA for
Chagas was not done for all of the blood stock. So it is very probably, I do not say how many, that
in this country many persons have become infected because the screening was not done, but now
we have the security that it is done, and this has also led to that the prevalence of chronic Chagas
has risen because more are being diagnosed [correctly]...so it has also benefitted the patient that all
the donors are screened...all the persons who receive blood, if needed, also know that it is safe
blood. They screen for HIV, for Syphilis, Hepatitis B and C, Chagas disease, and the other one
is...let me see...I already mentioned HIV, Syphilis...yes, those are the ones that they principally
screen for. So I consider that a benefit.
For the health personnel who work at community level another one of the important benefits has
been an important interaction with the community as the implementation of the community
epidemiological surveillance...this has helped in that the health establishment has more contact with
the community, and the community also has more [contact] with the health establishment, and that
level of coordination permits that people collaborate more. Not only in Chagas, in all the aspects of
health...so Chagas is like a trampoline in the sense that we help with Chagas but also, look, there are
also other diseases like Dengue, Malaria, Leishmaniases...for example...where it is necessary to
keep the house clean...there is made use of the opportunity [of more interaction with the
communities]...for example for the water which is covered to avoid that the mosquito Aedes [type of
mosquito which transmits fx. Dengue] deposits its eggs...so you end up doing something integral,
not only for Chagas, no, it is everything that has to do with health...with basic sanitation.
PR: Do you know if that collaboration has functioned in the same way here as in the other
countries, or if there have been differences as to the manner of collaborating between the different
entities?
VM: Yes, normally the experience that...in the meetings of IPCAM, which I mentioned, the
countries’ experiences...they always mention that PAHO is a ”NATO” ally...it is an ally which in
some countries...like in Nicaragua, the Ministry of Health is...PAHO, the office is within the
Ministry of Health, in Panama PAHO’s office is within the Ministry of Health...so this closeness
and this support of PAHO to the Ministry of Health always permits an ease in implementing. Not
always but most of the time it works. The experience, as I already mentioned, often has to do with
form, as you know, the (idea – [it sounds like this])...the rest of the colleagues from the other
countries have approved (the idea). But it is necessary to remember that each country has its
particularities in the Ministry of Health. The case of the Ministry of Health in Guatemala where
they have had 4 or 5 Ministers of Health in 2 years because of political questions. This does not
permit that they have a continuity in all the work and the advances. Chagas has been one of them,
right? Not because they have anything against [working with] the disease but rather because once
they change the Minister, the new Minister of Health comes with his own people of confidence, and
there are changes in the majority of the trusted positions so...the theme of vectors, Dengue is one
of...Dengue is generally managed by the Vector [control unit] which manages Dengue, Chagas,
Leishmaniases...the Vector [control unit] has been one of the cases...one of the diseases which even
can make a Minister of Health lose his job in the countries like Guatemala where there was a
Dengue epidemic 2 or 3 years ago, there were a number X of deaths, and that led to that the
Minister of Health lost his job. So that situation...there is also the case of Nicaragua where there is
much collaboration, in Costa Rica there is also much collaboration but that does not mean that the
things always go as one would hope for. In Honduras there is also much collaboration, but
nevertheless, remember that often...even though PAHO is very present, the limitation of PAHO is
that...no, it is actually not a limitation but rather it is a mandate that we have of not forcing the
Ministries of Health to do and implement something which they are not convinced about. Even
though we, let’s say...technically you can lay the foundation but they [MoH] end up deciding
internally if they will implement it or not. Like the case of Strout’s concentration method which is
being implemented, and that has permitted that there are more diagnoses of acute Chagas.
PR: Also in our meeting yesterday with Ing. Romero and Dr. Gavidia we became aware that El
Salvador reformed its health system in 2009, which coincided with a report by PAHO about
primary health care and Integrated Health Service Delivery Networks. And therefore, we were
thinking about if PAHO also participated in that reform in a role as supervisor or something like
that?
VM: I don’t know if you read it but there was a change of government in this country in 2009 when
the government of the official party which was the ARENA, Alianza Republicana Nacionalista,
right-wing, changed...in came FMLN, right?, in 2009. And with the change of government there
were also changes in all of the state’s institutions, including the Ministry of Health. The minister
came, and was put in charge by the FMLN, Dr. María Isabel Rodríguez...within the vision that the
government had...one of the proposals that the official party [FMLN] sold [in the campaign] and
which was accepted by the population, as the Front, FMLN, won, was the health reform. With the
arrival of Dr. María Isabel Rodríguez this reform started to have a lot of upswing, and the reform
basically implied the creation of the integrated networks, the RIISS, integrated networks in health
attention, right? And also something known as the ECOS, which are the community teams of family
health.
Let’s say that the logistics are...this is El Salvador, this whole table [where we sit], 5 regions of
health, 17 SIBASIs which are administrative units under the region of health. under the ECO there
are community units of family health, and under the community unit of family health are the ECOS
which are exactly in the community. But all this and the support which has been given and provided
in order for this to be able to be successful...because of this support, because of this vision that was
there, PAHO provided provided a lot of assistance and technical support for the conceptualization
of how the networks should function, and the networks not only imply the theme of referral and
return of the patient but also a series of basic attentions that should be given through the community
team of family health, the ECO...the update of the clinical file on the family’s health...likewise the
necessity of knowing those needs...but you have to remember that when you, as in this case, go to
the community level, a whole lot of necessities surface. And probably the institutional capacity...we
are a country of medium income where the [part of the] gross domestic product which is invested in
health is not that high as in other countries, and that also limits the sufficiency of the budget, which
is intended for the Ministry of Health, to cover all these demands and needs. So there are many
needs which have been covered little by little, and the theme of the extent of coverage at the
community level has been covered with the creation of the ECOS. But the reform has still not
reached the whole country...there are places which have been more successful than others but that
also implies the necessity of having financing at one’s disposal because if you are going to have an
ECO in the community, it means that you should contract new human resources: a nurse, a doctor, a
health promoter...so all these necessities...the need to have financing at one’s disposal, to have a
budget which permits that the health reform can be expanded. It doesn’t mean that what has been
done so far is bad, on the contrary it has been very beneficial for the population. However, we are
still going down this road but the whole country is still not covered with ECOS...you can enter the
website of the Ministry of Health, and there is a basic document that talks about the level of
functioning of the RIISS.
PR: Yes, we have already seen it.
VM: And this document talks about how it is structured, how it functions etc. and that has permitted
that even...through PAHO...or even the system of agencies of the UN has at some point supported
that the financing in other areas could also permit...because, for example, the theme that an ECO
can have...to make a diagnosis of needs in a community does not only have to do with health...often
there the problems that they do not have a home, that they do not have drinkable water, they do not
have a lavatory, and that is not only the responsibility of health [authorities], it is out of reach of its
mandate as such...buy yes, it has been important.
PR: Yesterday we also became aware that the Chagas program sometimes make recommendations,
for example about improvements of houses or of basic conditions but, I don’t know if you know
this, but in reality is it possible for the communities to follow these recommendations?
VM: Not always, not always. Currently...there was a project with the University of El Salvador of
ECOSALUD in which Dr. __ (Abregu), I think that was his name, was there...where they had...they
administered some funds, and with these funds they were in the zone of Verapaz, in the department
of San Vicente, working on wall improvements...what they mainly did was to fill up the cracks,
right? So that the insect could not live there. They...the interventions that they did...we as PAHO
have not assisted in that moment the...the house improvements...it is not our strength...mainly the
theme of health [is their strength]...but nevertheless, the theme of Chagas disease is a theme which
you want to bring to the mayors’ offices for support...because the mayors’ offices, in the programs
which they execute in the communities, they have a percentage of what is called the Fund for Local
Development, the FISDL3, which is an institution that coordinates with COMURES which is the
community of the mayors from the 262 municipalities...and they are the ones who can give the
support through their internal project. But yes, health [authorities/personnel] has been involved
directly in seeing those needs but we believe that the recommendations and the work in the
communities is a very important support which should be discussed exactly at the community
level...
Therefore it is important that the successful experiences that have been in the coordination between
the mayors’ offices, the communities, and the vector control [units] can be brought to another
level...also to systematize and diffuse to see what they did and how they did it...which has been
achieved: there is a very important experience in the department of Usulután, a document which we
are revising with Ing. Romero that we believe will be ready for release in January...where there was
a very important participation of the mayor, right?, and of his council in managing the Chagas
disease control in the department of Usulután. So that is going to be like a model which could be
used in the future.
PR: And another thing with this reform of the health system. In your opinion, has community
participation increased through this reform?
VM: Yes, the answer is convincingly yes. Because the health reform has permitted that the
committees of local leadership, at the community level, can develop and be carried out. This implies
a very tight coordination between the community, and its internal organization, with the ECO, with
the UCSF4 [Community unit of family health], with everything that is the scheme of the Integrated
Health Service Delivery Networks, with the RIISS...and the work has been very important because
it has also permitted that many of the interventions of the interventions of the health unit, or the
community unit, go hand in hand with the needs of the communities. Of course, it is not always
possible to give a solution to all the problems...communities which possibly have been abandoned
for a long time have a number of needs...where health [authorities, personnel] hardly can come to
3
4
Fondo de Inversión Social para el Desarrollo Local
Unidad Comunitaria de Salud Familiar
houses, they can hardly come to construct bridges, streets neither because it is not their job, and it is
there that the integration with other institutions of the state, or another organism, has a very
important role.
PR: We would also like to know what the advantages of the Integrated Health Service Delivery
Networks are in comparison with the old system...that is, what problems were related to the
fragmentation of the health services before?
VM: You know, fundamentally the theme has to do with, firstly with the access of the population to
the health services...that is one...before it did not exist. The person had to go to a health unit when
sick, now the health unit goes to the person...they go to the homes...they do the domiciliar visits,
they diagnose there, they treat there, and if there is a need to refere, they refer. Because each one
has its level of competence and of attention...before that did not exist...secondly, before...you, the
person went, was given a referral for a higher level of attention, and you would not know if the
person could attend at the other place to treat his health, his disease, or his case...you would not
even know if the person from this other place would come home with some indications. Now, all
that, at least where the reform has been done, there is coordination through the Integrated Health
Service Delivery Networks about availability of medicine, availability of
immunizations...medicines principally, follow-up of other types...pregnancies for example. So the
level which is there has improved importantly but, as I repeat, if you are closer to the community or
the persons, there are more needs that are diagnosed. The nutricional theme for example...which
was there before...there is possibly more nutritional issues than what was believe before because
now they are being diagnosed...a bigger work is being done at the community level. So the reform
has also contributed very importantly to the coordination with other institutions, NGOs, social
security, (school welfare)...all these institutions who are part of the national system of health. This
coordination has done, as I already mentioned, that the interventions of all these institutions can join
up and address a problem in such a way that if institution X plus the Ministry of Health...if this
institutions was going to coordinate deworming, it would do it together with the Ministry of
Health...because those who they do not cure, the Ministry of Health could cover the rest.
It [the increased coordination] can also help in the matter of social security, the areas of intervention
that they have, remembering that social security only assists the persons who are insured...but it is
important to know that if this person stops working, then he is not a beneficiary of social security,
and therefore if he has a chronic disease or [needs] a special follow-up...if follow-up is still needed,
this person will not see social security, but there is the Ministry of Health which ends up deciding
who will assume the responsibility of the follow-up of the treatment. Principally chronic diseases of
long duration such as Diabetes Mellitus, Arterial Hypertension, and Oncological problems, Cancers,
or of other character...therefore it is important that now, through the reform, the institutions...that
the other health institution coordinate. There are always limitations as with everything else,
improvements are needed as with everything else but we believe that we are on the right path.
PR: We also have a question about the beginning of the Chagas program and also about the
objectives for the future.
VM: Yes. I wanted to ask you...because I have a meeting at 12:30 in the Ministry of Health...but I
wanted to ask you if we could continue tomorrow?
PR: Yes but we actually only have two short questions.
VM: Ahh OK, that’s fine..I...that’s fine.
PR: Perfect. We just wanted to know if there were specific conditions which the Central American
countries had to comply with to get the technical support from PAHO? That is, was there a specific
way of organizing the health system that they had to do?
VM: Ahh OK. It is interesting that question. The answer is no. There are no specific conditions in
the sense that...you have to remember that the World Health Organization is made up of...it is an
institution...but what they practically operationalize and execute are mandates that are taken through
the World Health Assembly. And in that World Health Assembly...are the Ministers of Health
and/or delegates are the ones who make up that World Health Assembly, and they are the ones who
end up taking the decisions about directives/guidelines/norms of all the types that have to do with
health. It means that the moment when all the Ministers of Health, or all the delegates from the
countries, approve it [and intervention etc.], the WHO operationalizes it through PAHO, and PAHO
coordinates with the Ministry of Health. But this Ministry of Health, the head of the Ministry of
Health who is the Minister of Health already went here [pointing to what he is showing with his
hands – the World Health Assembly]. Therefore, what WHO wants to implement in some countries,
fortunately comes by a mandate which was previously agreed upon with the Ministers of Health.
This means that the conditions of each country...that independently of its social, political, and
economical state it is being implemented, right? and it is therefore that the advances...in some
themes there is more progress, in others there is less. We have had important progress with theme of
maternal mortality for example, and the rest of the diseases that I mentioned...so this is why that
you do not see it [specific conditions], and furthemore there is another thing. The Cooperation Bank
(??) of PAHO always gives through...not only as PAHO, but of all the agencies, of all the 11
agencies of the UN, they establish an agreement, an alliance with integral relations with the
Minister of Government and through this an agreement is signed on the technical cooperation. And
in that agreement of technical cooperation is the theme of (the invitation), local development,
security, health, alimentation, risk management...so in this __ framework of the cooperation of the
countries which we also __ __. So the government puts in the conditions...PAHO practically puts in
the technical support and some financing which it has to work in these specific areas.
PR: Perfect. Finally we just wanted to know...because we have read that between 2011 and 2015 it
was an objective to eliminate the domiciliar infestation of the T. dimidiata but we have also read
that this is probably not possible because it is a native chinche and it also lives in the nature. But we
would like to know what could be a realistic objective?
VM: What happens is that...it is true that it was a goal, like an important objective for 2015.
Actually, the 6th objective of the MDGs, the Millennium Development Goals which have now
transformed into the Sustainable Development Goals, the SDGs, was committed to accomplish this
goal by 2015. However, in the case of El Salvador it has not been achieved...perhaps in the
framework of the SDGs there would have to be worked on this...because it is an important
challenge that it is a native chinche, as you already mentioned. And as long as the socioeconomic or
environmental conditions of the homes do not improve, it will be difficult to be able to eliminate it.
But it is also necessary to take into account that we often focus on the homes. ”the homes, the
homes, the homes”. But it is necessary to remember that if this chinche is not in the home it is
generally also around in the peridomiciliary part, and there are also other intermediary hosts, not
only birds, we also have dogs, we also have wild animals, and there is even a project...there is an
investigation which we proposed to Ing. for this year [I think he means 2016 – see further
below]...to see if it was possible to evaluate the importance of the dog...as there are one or more
dogs in the majority of homes...mostly in the rural area. So the importance of the dog as an
intermediary host of Chagas disease. Because often it [the chinche] has not been found in the house
but outside. But how much importance do the dogs have in this regard? The dogs and other animals.
A study was done in Guatemala where 30, 40% of the dogs were infected, if I am not wrong. And
that in the acute phase, right? So....by the Trypanosoma. So were are going to see if we can support
Ing. Romero in this, this year [2016]. But yes, that would be it [an objective for the future].
PR: Well, finally we just would like to know if there is something important which we have not
asked about, or if there is something you would like to add?
VM: Maybe to ask what the thesis is about? Ing. Romero mentioned that it is a thesis...
PR: About the programs in El Salvador, Honduras...Central America. We have also done an
interview with a representative from Doctors Without Borders [MSF] who are in Bolivia, and more
than anything we would like to find...like best practices or something that future programs can use...
VM: You talk about best practices...JICA recently...there is a CD which they made about best
practices in Central America...it was....
PR: Yes yes, we have the report. Well, so we would just like to thank you a lot for your time, and
we would also like to mention that the investigation is only for our thesis, and we do not have the
intention to publish it. But if we will get the opportunity [to do so], we will ask you again for your
consent.
VM: Sure. Remember that the theses which are not published, do not serve. So it has to be
published.
PR: That is why...if we get the opportunity to do it, we will ask for you consent.
VM: Yes yes, with pleasure. And in case you need something more which we have missed, feel free
to ask me. There is...Ing. Romero forwared the mail you sent.
PR: Ahh OK. Because we actually tried to send you a mail but...
VM: It is because the mail [address] which he [Romero] had was wrong. But the last mail he sent
me, which he forwared from you...that mail works...but yes, you will have to excuse me because of
the time...I have to be there at 12:30 but that is why I mentioned that if you need something more,
or if you want to talk about another theme, I will be glad to...
Entrevista con Dr. Victor Mejía, OPS
[intro + vi spørger om OK at optage osv.]
PR: Bueno, ante todo queremos agradecerle mucho su tiempo y su participación que es muy
importante para nosotros porque ya hemos leído muchos documentos y muchos informes, pero nos
ayuda mucho hablar con las personas que realmente están involucrados en los programas....
Y bueno, para empezar, hemos leído que la OPS más que nada ha proporcionado apoyo técnico, vía
reuniones subregionales, seminarios y misiones de evaluación. Y en su opinión, cómo han sido
útiles esas reuniones entre los diferentes actores?
VM: Normalmente, en el plan de (trabajo), en la planificación de la OPS se hace bianualmente,
cada 2 años, y se planifica siempre en conjunto con un documento que es un documento base que se
negocia con los ministerios de salud al inicio del bienio, digamos el bienio que va a (abarcar) 2
años. Y ese documento base es donde la cooperación de la OPS se enmarca para trabajar y evaluar
cada 6 meses. En este caso, si son 2 años se evalua 4 veces en el año, todas esas actividades que la
OPS, a través de las necesidades del ministerio de salud le plantea. En el tema particular de la
enfermedad de Chagas...como ustedes saben, la enfermedad de Chagas es una de las enfermedades
desatendidas...por tanto en este país, como en la mayoría de países en Centroamérica, el tema de la
enfermedad de Chagas es un tema institucional del ministerio de salud...mas sin embargo, el apoyo
financiero y técnico que se ha tenido generalmente está bastante limitado...en el sentido que, como
usted lo mencionó, que JICA, la OPS y otras instituciones como (GTZ) o (GIZ) actualmente que es
la Cooperación Técnica Alemana que en algún momento estuvieron interesados en brindar apoyo
para la enfermedad de Chagas. Nosotros como OPS, brazo derecho de la OMS digamos, tenemos
dentro de las páginas que ustedes han revisado de la OPS, hay planes estratégicos regionales, en
donde se enmarca básicamente el trabajo institucional encaminado en, principalmente, eliminación,
en el caso del país (verdad?) control e eliminación...en este caso de los vectores principales. Tanto
el Rhodnius Prolixus como el Triatoma dimidiata...en este caso, básicamente, en nuestro país la
mayor cantidad de vectores que tiene es el Triatoma dimidiata...en el 2010 el país fue declarado
libre de Rhodnius Prolixus, y hasta este momento el chequeo entomológico que ha tenido el
ministerio de salud no lo han encontrado...sí, han encontrado un nuevo vector, que no (está/ es tan)
nuevo pero se creía desaparecido que es el Triatoma Ryckmani...principalmente en las zonas del
oriente...Usulután, San Miguel en la zona oriental está identificado...pero volviendo al
punto...entonces nuestro trabajo fundamental consiste en brindar asistencia técnica y, tal vez no
tanto, el apoyo financiero porque, como ya mencioné, el apoyo financiero que se tiene normalmente
para estas enfermedades es poco...el país está haciendo un buen trabajo en el tema de control, y
aparte de eso se tiene la ventaja que el veneno, la Deltrametina o el veneno que ellos aplican para el
control de Dengue, para el control de (anopheles/anophelis) en el caso de la malaria también es un
veneno que también tiene un efecto importante contra el triatoma...entonces de alguna manera, el
que nosotros, el país, el ministerio de salud aplique este veneno en las casas, el rociado, es que ellos
hacen en forma permanente...todas esas acciones de control e intervención que están teniendo han
dado buenas resultados indirectamente (4:30) porque el interés es evitar (__) o anopheles (__), pero
indirectamente se ha estado controlando también la población de triatomas...mas sin embargo, a
pesar de que el ministerio de salud ha tenido un trabajo muy importante en las acciones
antivectoriales y de control en el diagnóstico de los casos también agudos y la detección de los
casos crónicos...también hemos visto la necesidad de que ellos focalicen sus intervenciones en
zonas principalmente fronterizas con los...departamentos...con los, perdón, países de Guatemala.
Por qué? Porque...resulta que...hemos visto una importante carga de las personas migrantes que
migran al país de otros países, pero aparte de eso, los algoritmos de detección y de diagnóstico hasta
este momento no habían sido, en el caso de Guatemala, mejorados para la detección de pacientes
agudos...hace 2 años se hizo un proyecto cooperativo con el gobierno de Guatemala y El Salvador,
los ministerios de salud de Guatemala y El Salvador, la OPS de Guatemala y El Salvador, en donde
se intervino prácticamente en las zonas fronterizas de Ahuachapán y Santa Ana fundamentalmente
con el intercambio de información, con estandarización de los algoritmos (de) diagnóstico de
laboratorios y con el manejo clínico del paciente agudo, y se fortaleció mucho en ese caso el recurso
humano, la capacidad diagnóstica de laboratorio, pero aparte de eso el tema de la vigilancia fue un
eje fundamental...tuvimos muy buenos resultados tanto así que en el caso de Guatemala ellos han
estado diagnosticando, de forma más oportuna, los casos agudos ya que ellos, ante de ese proyecto,
tenían más cantidad de casos crónicos y para que el caso, lógicamente, llegue a enfermedad de
Chagas fase crónica, tuvo que haber pasado por una etapa aguda. Y el detalle o los
(criticos/criterios) está identificar el caso agudo, (6:40) principalmente aquellos casos, en donde los
signos y síntomas son pocos...porque no vemos ahora muchos casos con el signo de Romaña,
florido, tosis...las personas generalmente buscan un tratamiento alternativo, automedicándose o
buscando una opción de medicina alternativa como el curandero o en la misma familia las abuelas o
los abuelos dan medicamentos que muchas veces no son para eso...y eso hace que la etapa aguda
tienda a ocultarse...como ustedes saben...(será) por si misma de 2 a 3 semanas, y para pasar a una
etapa subclínica y posteriormente a la etapa crónica...y muchos de estos niños o adultos
probablemente nunca van a saber que tuvieron enfermedad de Chagas...mas sin embargo cuando ya
hay problemas cardíacos...principalmente en nuestro país es problemas cardíacos...(7:30) el
(hipertrofia) cardíaca...ya cuando estén en una etapa crónica avanzada es cuando se diagnostican
como enfermedad de Chagas crónica...sin embargo, otro detalle importante es que como... el
tamizaje que se hace en los bancos de sangre es al 100% de la sangre...se ha visto allí es donde se
identifica que tenemos un porcentaje...bastante alto de enfermedad de Chagas crónica...no tengo el
dato, ahorrita de la mano del año 2015...mas sin embargo hemos visto que inclusive en 2 o 3 veces
más alto el Chagas crónico que el VIH o el Hepatitis B...eso significa que sí se están diagnosticando
en la etapa crónica, no se están diagnosticando en la etapa aguda, ni mucho menos dando
tratamiento en la etapa aguda.
El tema del diagnóstico de los casos agudos también tiene que ver con la disponibilidad de
medicamentos...porque (usted) lo diagnostique en la fase aguda – uno: tiene el sistema de salud la
responsabilidad y la obligación de dar sus medicamentos...
PR: A todos los casos....
VM: A todos los casos, según la normativa. Pero el problema que se tiene es que el Benznidazole o
Nifurtimox...es que hay el problema que tenemos es que esos medicamentos...que localmente no
existen casas comerciales que lo oferten porque la cantidad de casos es tan pequeño que al año
andan entre promedio de 5, 6 casos al año – agudos, y por lo tanto las casas comerciales para ellas
no es un negocio ofertar una cantidad tan pequeña de tratamiento.
PR: Pero es porque no se detectan todos los casos, o sólo...
(9:13)
VM: Creemos nosotros que hay un subregistro....un....más que un subregistro, quizás un
subdiagnóstico...un subdiagnóstico porque si la prevalencia de la enfermedad de Chagas crónica es
2 o 3 veces más alta que la de VIH, y la cantidad de casos agudos que se están diagnosticando es tan
pequeña como 5, 6 al año, significa que hay un porcentaje importante que en la etapa aguda pasan
desapercibidos o maldiagnosticados o sencillamente las personas no consultan...
PR: También es por el hecho de que la enfermedad muchas veces es asintomatica?
(9:50)
VM: Sí, exactamente. De hecho, el Dr. (Salvatela) que es un médico que, digamos, es el encargado
en la OPS a nivel regional en el tema de Chagas y él está en Uruguay, comentaba en una
conferencia que el experiencia que él tiene de muchos años...han visto que solamente del 20 o 30 %
de los casos de Chagas agudo presenta el signo de Romaña...mas sin embargo en nuestro caso lo
interesante ha sido que sí, casi casi el 90-95 % de los casos agudos han presentado signo de
Romaña...pero las personas consultan por ese signo de Romaña...mas sin embargo desconocemos de
qué porcentaje pasa a una etapa asintomática o sencillamente subclínica o las manifestaciones son
tan leves que las personas con una Acetaminophen ya mejoran y ya no buscan...por eso mismo...y lo
vemos con el Ing. Romero, tenemos una deuda pendiente con las personas que tienen enfermedad
de Chagas crónica. Principalmente porque estas personas ahora en la norma nacional de Chagas del
ministerio de salud, acorde a la evaluación que hace clínica el cardiólogo o el internista, el 100% de
los casos deberían de recibir, bajo ciertas condiciones, su tratamiento en la fase crónica. Hay un
estudio, no lo tengo, es muy interesante, creo que el Ing. Romero lo tiene, donde en el hospital
nacional Rosales que es el Hospital Nacional de Referencia de tercer nivel en el país...hace 2,3
años, un poquito más...hicieron un estudio donde evidenciaban que un 60% de las pacientes con
enfermedad de Chagas crónico terminaban siendo seronegativos a la hora de hacer el control del
ELISA después de su tratamiento de 60 – 90 días. Entonces eso da (yo) la pauta para pensar que sí,
realmente el medicamento, el Nifurtimox, en este caso podría dar una opción terapéutica importante
en el caso de los pacientes con la enfermedad de Chagas crónica. Pero sólo para aquellos pacientes
en los cuales el ELISA para Chagas sigue siendo positivo...recordando que los problemas
cardiológicos de hipertrofia o bloqueo de rama, eso ya no pueden, eso ya no son reversibles...sino
más que todo es para mantener el estado serológico porque una vez esté dañado el corazón, ya no
hay vuelta atrás, salvo esté en una etapa bastante temprana...del diagnóstico del hipertrofia, hay
medicamentos que usa el cardiólogo para que eso ayude al corazón y tienda a mejorar su calidad de
vida la persona...pero si hay eso insuficiencia cardiáca o una hipertrofia bastante avanzada,
normalmente la persona sólo está con medicamentos para suplir un poco diuréticos, (forazimide), u
otros...mas sin embargo, como mencioné esos estudios han sido pautas muy importantes para poder
incluir el tratamiento de los pacientes crónicos.
PR: Perfecto. Y mencionó el apoyo técnico, pero específicamente, en qué ha...
(13:10)
VM: Sí. Son 4 cosas, básicamente, las que se hace. Primero...con la Dirección de las enfermedades
infecciosas y la Dirección de saneamiento ambiental que es donde está el Ing. Romero es con ellos
se coordinan capacitaciones para el diagnóstico clínico, para el tema de la vigilancia entomológica,
para el tema también del...son encuestas serológicas también...hace 2, 3 años fue la última encuesta
serológica que hizo JICA...nosotros desde hace 3 años no hemos apoyado encuestas serológicas,
solamente un estudio, que le comenté, se hizo hace 2 años en la zona fronteriza...y el otro tema es
que nosotros hemos apoyado también para...cuando ha habido las reunios regionales de la IPCAM,
que es la Iniciativa en la eliminación de Chagas en Centroamérica, hemos financiado también que
personas vayan de El Salvador del ministerio de salud a esas reuniones, y también hemos apoyado
con asistencia técnica para poder...que el programa nacional tenga su normativa actualizada de
enfermedad de Chagas...(14:30 ca) para esta nueva normativa que aún está en proceso de revisión...
ha solicitud...el ministerio de salud se pidió que en un solo documento se incluieran todas las
enfermedades vectorizadas. Ahí está Malaria, está Leishmaniases, está enfermedad de Chagas en un
solo documento. Pero aún está en revisión y sólo se (tiene) una versión previa, mientras no esté
aprobada se sigue usando la norma anterior. Entonces esos elementos son los que la OPS
principalmente brinda apoyo.
(15:05)...muchas veces se tiene también apoyo cuando el ministerio de salud no ha podido, dentro
de su programación normal de compra, comprar el ELISA para Chagas...esto de (Chagatec)
normalmente es lo que las casas comerciales lo tienen entonces...y si hay fondos disponibles, se
apoya para que el...el laboratorio nacional de referencia, en este caso la Lic. (Marta Eliza)
Fernández que hace la parte parasitológica o en el caso también...hay otra Licenciada que no
recuerdo el nombre...hace la parte serológica a la hora de hacer la confirmación de los...de la
enfermedad de Chagas crónica principalmente...entonces compramos reactivo para ellos también...y
bueno lo que ya mencioné, la capacitación que se hace con el personal cuando se manda
afuera...también hemos apoyado cuando ha habido necesidades de (reproducir) un material
educativo con la enfermedad de Chagas...(16:03) mas sin embargo, sabemos que el financimiento
no es suficiente pero con lo poco se tiene se ha estado apoyando el ministerio de salud.
PR: Y las misiones de evaluación que se han hecho, cuáles son los indicadores que se hacen para
evaluar los programas?
(16:23)
VM: Sí. Normalmente la evaluación que se hace con la enfermedad de Chagas son principalmente
indicadores entomológicos, verdad? porque una...el...usted ya lo mencionó...el programa de Chagas
es un programa muy vertical. El Ing. Romero, él es...el Ing. (es número uno) y su enfoque es
entomología, verdad? Entomología...mas sin embargo cuando se evaluan, con las 5 regiones de
salud que hay en el país, todos los indicadores que se hacen son entomológicos pero también hay
indicadores de vigilancia...cuando tienen que ver los porcentajes de detección de casos,
seguimiento, curación...todos esos indicadores están en las evaluaciones...el año anterior...el
año...creo que la última evaluación...porque como nosotros no hemos podido financiar...este año no
pudimos financiar evaluación, el año anterior sí...todas esas evaluaciones se hacen y las tiene el Ing.
Romero...la mayoría de lugares o de personas que presentan de todas la regiones de salud salen muy
bien evaluados...pero nuestro crítica o comentario siempre al programa de vectores está que a pesar
de que ellos cumplan sus indicadores de detección, de diagnóstico, de entomológico, de chequeo de
casas, de ver si la chinche está positiva en sus (heces), a pesar que salgan muy bien evaluados con
su numerador y denominador seguimos teniendo enfermedad de Chagas crónica, seguimos teniendo
casos agudos...por lo tanto nosotros queríamos, queremos que ellos mejoren o evaluen o
reconsideren si esos indicadores verdaderamente están dando respuesta a la necesidad que se
tiene...porque, para poner un ejemplo, en la zona de occidente hay 3 departamentos: Sonsonate,
Santa Ana y Ahuachapán...de los 3 departamentos...son 3 de los departamentos donde hay mayor
cantidad de casos de enfermedad de Chagas...siempre salen muy bien evaluados...pero si salen muy
bien evaluados, no debería de haber casos de enfermedad de Chagas, ni crónica, ni aguda. Entonces
volvemos al mismo tema, entonces será que la información que ellos están dando o brindando no es
tan real como se visualiza...por eso necesitamos también otra cosa que hemos comentado al Ing.
Romero que se necesita un monitoreo, una supervisión más cercana antes de la evaluación para que
los indicadores que ellos presenten en las evaluaciones realmente reflejen el trabajo o la realidad de
las comunidades...porque si no, usted tiene indicadores – muy bien, 100%, muy bien, OK todo, pero
los casos en las comunidades que muchas veces no han sido diagnosticados y detectados...un
trabajo muy importante que se hizo con JICA fue la vigilancia entomológica comunitaria donde las
personas capturaban las chinches, los metieron en una bolsita y las iban a dejar a la unidad de salud
más cercana. Ese proyecto se sigue dando, se sigue sosteniendo, se sigue implementando, pero
nosotros...la última vez que conversamos con él era necesario que se evaluara realmente si estaba
dando resultados...porque también hemos detectado de que muchas veces las personas hace...en la
vivienda en la comunidad capturan las chinches, las meten en el frasco, las van a dejar en la unidad
comunitaria de salud familiar, pero de aquí ya no las envian al siguiente nivel que es donde hacen el
diagnóstico que está a nivel de los SIBASIs, los Sistemas Basicos de Salud Integral...entonces si él
se toma el tiempo, la persona, para capturar la chinche, para ponerla, para ir a dejarla en la unidad
comunitaria de salud familiar, por qué la unidad comunitaria de salud familiar no envia
oportunamente y cuando las chinches están vivas al SIBASI adonde corresponde?
PR: No hay por qué, si no lo hacen...
(20:34)
VM: Si no lo hacen, queda aquí. No es en todos, pero sí hemos visto casos donde personas que han
estado enfermas o que diagnosticaron Chagas agudo han hecho eso con las chinches, pero no llega
acá la información, entonces aquí en este paso hay un...hay una limitante...porque muchas veces
también la otra cosa que hemos visto, como no hay perfección en esto, es que muchas veces el
director de la unidad de salud o el médico que está ahí muchas veces son en año social. Entonces
son médicos que no se han graduado todavía que están en su octavo año, en el año social, y a veces
por la falta de experticia, de conocimiento, no le toman la importancia en seguir la cadena que
debería de llevar. Entonces, esa limitante, sí la hemos ya identificado y lo hemos comentado...se ha
tratado de corregir...mas sin embargo, de nuevo, si todo esto realmente funciona también, por qué
seguimos teniendo casos de Chagas crónico? Por eso también...otra de las cosas que hemos
comentado con el Ing. Romero es la necesidad de elaborar cursos en línea o cursos de capacitación,
algún mecanismo para...no solamente que los entomólogos estén diagnosticando y (microscopistas)
que ven la lámina de gota gruesa y identifiquen el parásito, sino también el médico que está en los
establecimientos de salud se actualice en la enfermedad...porque puede...conozco casos de hace 2
años, que le comenté, que hicimos el proyecto con Guatemala en donde nosotros estuvimos en
campo viendo los casos de Chagas agudo, casos que ya estaba en la etaba crónica que fueron
agudos y cuando fueron agudos, los niños de 7, 8, 9 años cuando su papás los llevaron a la unidad
de salud, el médico que los vió o que los consultó o que los atendió terminó dándole unos colirios
para los ojos pensando que era una infección bacterial...entonces nunca pensó que podía ser otra
cosa, y en ese momento fácilmente pudo haber enviado una gota grueso...o tomado sangre para
Concentrado de Strout y ver el diagnóstico y de haber dado tratamiento oportunamente...otra cosa
que hemos visto es que se necesita mayor seguimiento con los casos agudos que reciben tratamiento
porque en ese caso, usted sabe que el tratamiento de un caso de enfermedad de Chagas agudo se da
por kilogramo de peso, y muchas veces hemos visto casos donde...han sido muy mal manejados
(entonces?) el médico viene, gestione el medicamento y le da al paciente...”aquí está su frasco de
medicamento, su dosis para 90 días” y esta persona se va a su casa. Pero la persona piensa, como
nadie los está supervisando, él queda a su discreción, a su criterio, (se hice) tomar el medicamento,
pero cuando la persona ya se le quita, pasó, y él o ella cree que ya se curó...entonces ahí falta un
componente educativo importante también...verdad? porque a veces está tan saturado el
establecimiento de salud que la parte educativa no se está dando.
PR: Se necesita más seguimiento del doctor?
(23:55)
VM: Las dos cosas: la parte educativa...explicarle a la persona que a pesar de que se le quite, no
significa que ya se curó hasta que se trate...el seguimiento del promotor de salud a la persona...este
país es muy exitoso, el ministerio de salud con programas como VIH, como tuberculosis, como
malaria que estamos en la etapa de eliminación...mas sin embargo, Chagas nos ha quedado
detenida...como ya mencioné, las evaluaciones pueden salir muy bien, pero si hemos detectado
nosotros esas limitantes, esas dificultades, y es que también se necesita mayor seguimiento de el
médico, del promotor de salud, de los epidemiologos, de la misma comunidad inclusive, verdad?
Porque, repito, si la persona se lleva la cantidad de medicamentos y él o ella ya se siente sano, se
siente muy bien, él ya no ve la necesidad de tomarse medicamentos...con este trabajo que hicimos
en el 2012 con Guatemala vimos que había personas que...a pesar de habersele explicado en su
momento oportuno, según ellos, la enfermedad de Chagas no completaron sus esquemas de
tratamiento...tenía possiblemente 20, 30 tabletas aún del esquema de 90 días. Entonces...de 60 a 90
días dependiendo del medicamento...entonces como usted ya mencionó se necesita mayor
seguimiento de los casos...y otra cosa interesante es que este país lo puede hacer, y lo puede hacer
porque la cantidad de casos es bien pequeño. Otros países de Centroamérica donde la cantidad de
casos de enfermedad de Chagas es mayor, no lo pueden hacer por la misma logística que tienen. El
caso de Guatemala y sus zonas selváticas o Honduras y las grandes extensiones que tienen que
seguir para visitar las viviendas...acá es un país pequeño, tenemos 20.000 kilometros
cuadrados...usted está en occidente, en tres horas llega al oriente y ya atravesó todo el
país...Entonces esas cosas o esas situaciones son las que...en algún momento lo hemos comentado
con el Ing. Romero, él está consciente que se necesita mejorar varias cosas...y la idea de la
asistencia técnica es no quitar...en ningún momento, de dejar de dar el apoyo para la capacitación
del personal para el tema de la vigilancia, para el fortalecimiento del recurso humano, e inclusive en
cuando sí es posible para el fortalecimiento con equipamiento como microscopios por ejemplo en
donde ellos tienen una importante limitante a veces, y el diagnóstico que es bien importante.
Asimismo como ya mencioné, nosotros a través de la OPS se gestiona normalmente la compra y/o
donación del medicamento...porque OPS trabaja con un fondo que se llama el fondo estratégico o el
fondo rotatorio que en lo que consiste es que se hacen compras conjuntas para varias países de un
medicamento que normalmente no está disponible en el país. Por ejemplo ahora los tratamientos
para malaria, para paludismo no tenemos en disponibilidad, pero nosotros gestionamos el donativo
de medicamentos que estamos esperando que venga en enero. La misma historia para enfermedad
de Chagas, la misma historia para Leishmaniases...en __ (ca 27:10...timio) cualquier de los
medicamentos que se utilizan no están en disponilidad acá en el país.
PR: De hecho, estamos pensando, por qué se ha eligido utilizar el Nifurtimox en vez del
Benznidazole?
(27:30)
VM: Toda la decisión de cuál se usa o deja de usar salió de un consenso en donde se llamaron
infectologos, médicos infectologos, médicos internistas, y se evaluó las propiedades del
medicamento, y por eso es que se ha dejado en ese sentido en la norma nacional el uso de
Benznidazole y Nifurtimox...es decir los dos medicamentos están en el esquema...mas sin embargo
para nosotros es más fácil conseguir el Nifurtimox que el Benznidazole, y hay un tema bien
importante también que es la limitante que tenemos es que no podemos conseguir, a pesar que
hemos hecho el esfuerzo, medicamentos pediátricos. En el caso de los niños toca triturar la tableta
para que darles la dosis que corresponde. No hemos podido superar esa situación. Y el
medicamento es amargo, por lo tanto la tolerancia que un niño puede tener a la hora de ingerirlo es
casi obligado, no? Por los padres...y si el niño en un momento...muchas veces estos niños...quienes
los cuidan no son los padres, son los abuelos, y el abuelo no se complica y muchas veces no da el
tratamiento porque está haciendo eeeso y [el niño] está peleando dárselo etc. Entonces son cosas
que, como ya le mencionaba, por consenso se llevó a ese acuerdo de dejar el medicamento [en la
normativa?]...mas sin embargo, en la norma de...ha tenido un retraso importante porque está en
revisión desde el año 2012...estamos 2012, 2013, 2014 y vamos para el 2016 y nunca aprobaron la
normativa al interior del ministerio de salud. Entonces ahora que la apruebe, y si es que sale para
este año 2016, va a ser una normativa que va a haber necesidad de volverla a revisar porque ya tiene
4 años de desfase.
PR: Pero ustedes no la aprobaron o?
(29:24)
VM: No, es que el...nosotros damos el apoyo técnico en revisarlo pero al interior del ministerio de
salud hay una dirección que se llama Dirección de Regulación en donde ellos al interior del
ministerio de salud revisan todos los documentos y ahí con su equipo de abogados, con sus técnicos
dicen...revisan el documento si hay que mejorarlo o si procede. Una vez la Dirección de Regulación
ha revisado el documento, ellos lo envian al Viceministro de salud, el Viceministro de salud lo
aprueba, pasa a la Ministra de salud, y la Ministra de salud saca un...algo que se llama resolución
ministerial. La resolución ministerial lo que dice es ”en base a sus facultades técnicas y
constitucionales, la Ministra de salud aprueba que el normativo se puede usar en el periodo de tal a
tal”. Pero para llegar allá está en reevaluación (/regulación), y reevaluación ha sido...un talón de
aquí...importante en donde los documentos muchas veces pasan hasta 2 o 3 años y nunca salen de
ahí, y cuando salen, salen desfasado como en el caso de la normativa. Eso en vista de también
nosotros lo (hicimos) ver a...con nuestro representante Dr. Carlos Garzón, lo hicimos ver a la
ministra de salud, y ellos han hecho cambios al interior tanto así que el jefe que estaba de la
Dirección de Regulación fuera movido más otros técnicos y ahora creemos que eso va a ayudar a
agilizar todo esto proceso que se tiene.
(30:56)...pero volviendo al punto, nosotros sugerimos, recomendamos, no obligamos, y es el país el
que decide adaptar y adoptar los lineamientos que vienen desde OMS.
PR: Ellos no lo han apropado [MoH I guess?]...y ese es la norma técnica
VM: La Norma Técnica de enfermedad de Chagas, sí. Pero ahí viene el problema que yo le decía
que ahora, desde el 2012 pidieron que todas las enfermedades desatendidas fueran en un sólo
documento. Entonces ahí están, Malaria, Leishmaniases, Chagas, principalmente estas...rabia creo
también. Entonces, como es un sólo documento, entonces si ellos no aprueban ese documento, no
tenemos normativa vigente...sino que...hasta que no sea aprobado y firmado por la Ministra de
salud, el documento vigente es el anterior, verdad? El único que está aprobado...que es del 2011si
me recuerdo. Entonces ya del 2011 a 2015 tenemos prácticamente casi 14 años de desfase...perdón,
sí 2011...no tenemos 4 años de desfase. Entonces...se necesita que eso salga...todos están
conscientes que es una necesidad, todos. Pero creemos que ahora con el cambio de autoridades de la
Dirección de Regulación el próximo año ya vamos a tener un normativo listo.
PR: Perfecto. Bueno, usted mencionó las diferencias geográficas entre los países de Centroamérica,
y también mencionó los éxitos en cuanto a otras enfermedades aquí en El Salvador. Pero en su
opinión, en qué nivel es la capacidad de controlar el Chagas aquí en El Salvador en comparación
con los otros países? Es mejor aquí o...
(32:44)
VM: Lo que pasa es que el país...nosotros de alguna manera hemos apoyado para que el ministerio
de salud mejore su sistema de vigilancia, la detección de casos, la capacitación etc. Y eso ha hecho
que el país identifique, detecte o diagnostique casos agudos de Chagas. Si usted revisa los acuerdos
de la IPCAM que es esta iniciativa que...para la eliminación del Rhodnius prolixus...y T.
dimidiata...prácticamente de los países de Centroamérica el país que más identifica casos agudos es
El Salvador...
PR: Pero también por la capacidad de detectarlos, no?
(33:26)
VM: Porque de alguna manera están capacitados, tienen el conocimiento, y prácticamente el tema
de la enfermedad de Chagas en los países...en los departamentos que son fronterizos es un tema
obligatorio de vigilancia...en todo el país es obligatorio pero es más obligatorio en aquellos
departamentos que hay mayor cantidad de casos. Entonces eso ha hecho, y gracias también a la
capacitación que se ha dado para que las personas puedan estar actualizadas en el conocimiento
para diagnóstico de Chagas...es siempre estamos detectando más casos. Entonces los demás
países...(no)...[- no] conozco [I know] la situación de ellos de la mayoría...pero para el caso de
Guatemala, como ya le comenté, hace 2 años se hizo este proyecto ellos, ya están diagnosticando
enfermedad de Chagas aguda. Siempre diagnosticaba, pero ya diagnostican más. Porque ellos no
estaban utilizando Concentrado de Strout para el diagnóstico de la fase aguda. Sino que solamente
hacían la gota gruesa, la microscopia, y hasta los 3, 4 meses le mandaban un ELISA. No estaban
metiendo el diagnóstico, el Concetrado de Strout como parte del diagnóstico...como parte de los
examenes para el diagnóstico agudo. Con la capacitación se fue acá del ministerio de salud, se
capacitó a los técnicos, y ahora sí ellos están (notiendo = notando? 34:48). Porque muchas veces,
usted sabe, que si es una baja parasitemia o parásito de sangre, la gota gruesa y la observación
puede ser que no diagnostiquen. Pero sí el Concetrado de Strout ayuda a que en una baja
parasitemia pueden identificarse los parásitos de sangre.
PR: Cómo se escribe ese Strout?
VM: Permíteme: S – T – R – O – U – T. Concentrado de Strout. Un segundo.
[Han tager sin telefon].
PR: Otra cosa. En su opinión, cuáles han sido los mejores beneficios de la colaboración entre la
JICA, el Ministerio de Salud acá y la OPS? O sea, cómo han sido las dinámicas y cuáles han sido
los mejores beneficios?
(35:47)
VM: Bueno, nosotros como OPS tenemos lineamientos desde Ginebra de la OMS sobre
cumplimiento de este plan, que le comentaba, el plan regional de eliminación de Chagas...el
beneficio propio para nosotros ha sido que el país ha implementado muchas de estas estrategias. No
son nuevas, son las mismas estrategias que se siguen (desde) este año. Mas sin embargo se ha
estado dando enfasis más y siempre en el manejo y diagnostico de casos agudos y el seguimiento a
la enfermedad de Chagas crónico. El beneficio que ha tenido el ministerio de salud es que has
estado haciendo el diagnóstico de los casos aun con las limitantes que tienen...el seguimiento a los
casos crónicos aun con las limitantes que tienen. Pero ellos se han dado cuenta de la necesidad
(indi..directa) de por ejemplo hacer el tamizaje del 100% de los donantes de sangre. Antes, hace 1015 años eso no se hacía. Sino que aleatoriamente de toda la bolsa de sangre se seleccionaba un
porcentaja para hacer el tamizaje para ELISA para Chagas. Pero no a toda la bolsa de sangre se
hacía ELISA para Chagas. Entonces es muy probable, no digo cuánto, que en este país muchas
personas se han infectado por no hacer el tamizaje, pero ahora tenemos la seguridad de que sí, y eso
ha hecho también de que la prevalencia de Chagas crónico aumente también porque se está
diagnosticando más...entonces el beneficio también para el paciente ha sido ese que todos los
donantes tienen su tamizaje, todas las personas que reciben sangre (si hay necesidad) también saben
que es una sangre segura. Tamizan para VIH, para Sifilis, Hepatitis B, C, enfermedad de Chagas, y
la otra es, déjame ver, la VIH ya lo mencioné, Sifilis..sí son estas las que tamizan principalmente.
Entonces eso considero que es beneficio. Para el personal de salud que trabaja a nivel comunitario
otro de los beneficios importantes ha sido una interacción importante con la comunidad, ya que a la
hora de implementar la vigilancia epidemiológica comunitaria eso ayuda a que el mismo
establecimiento de salud tenga más contacto con la comunidad y la comunidad también con el
establecimiento de salud y ese nivel de coordinación permite que la gente colabore más. No
solamente en Chagas, en todos los aspectos de salud...sino que Chagas es como un trampolín en el
sentido que nosotros ayudamos con Chagas, pero también, miren, hay otras enfermedades también
como Dengue, Malaria, Leishmaniases...donde haya...hay que mantener la casa limpia...se
aprovecha para por ejemplo el agua que está cubierta para que la tapen y evitar que el zancudo
Aedes y desposita sus huevos...entonces se termina haciendo algo integral no sólo exactamente
Chagas, no, es todo lo que tiene que ver con el salud __ con saneamiento básico.
(38:50)
PR: Sabe usted si esa colaboración ha funcionado de la misma manera aquí como en los otros países
o si ha habido diferencias en cuanto a la manera de colaborar entre las diferentes entidades?
(39:27)
VM. Sí. Normalmente la experiencia que...en las reunios de IPCAM, que le comentaba, la
experiencia de los paises...siempre mencionan ellos que OPS es un aliado NATO...es un aliado que
en algunos paises...como en Nicaragua el ministerio de salud está...la OPS, la oficina está dentro del
ministerio de salud, en Panamá la oficina de la OPS está dentro del ministerio de salud...entonces
esa cercanía y ese apoyo de la oficina de OPS para los ministerios de salud permite que siempre
haya facilidad para implementar. No siempre, pero la mayoría de veces funciona. La experiencia,
como ya mencioné, muchas veces tiene que ver con la forma, como (usted __, la idea)...el resto de
los colegas de los paises han venido muy bien (la idea). Pero hay que recordar que cada país tiene
su particularidad en los ministerios de salud. El caso del ministerio de salud de Guatemala en donde
por cuestiones políticas en 2 años han habido 4, 5 ministros de salud. Eso no permite que tenga una
continuidad en todo el trabajo que se haya podido avanzar. Chagas ha sido uno de ellos, verdad? No
porque tengan nada contra la enfermedad, sino más bien porque una vez cambian al ministro, el
ministro de salud cuando llega a su propia gente de confianza, y hay cambios en la mayoría de
cargos de confianza entonces...y el tema de vectores, Dengue es uno de los...Dengue generalmente
lo maneja Vectores, Vectores maneja Dengue, Chagas, Leishmaniases...Vectores ha sido uno de los
casos....de las enfermedades que inclusive puede hasta quitar ministros de salud en los paises como
el caso de Guatemala, en donde hace 2, 3 años que hubo una epidemia de Dengue, hubieron X
cantidad de muertos, y eso hizo de que las mismas autoridades quitaran al ministro de salud.
Entonces esa situación se da el caso particular de Nicaragua donde hay mucha colaboración, Costa
Rica también hay mucha colaboración, pero eso no significa que las cosas siempre se vayan a dar
como uno experaría [As one would hope]. Honduras también, muy buena colaboración, pero sin
embargo recuerde que muchas veces, a pesar que la OPS esté muy al pendiente, la limitante de la
OPS es que no...de hecho no es una limitante, sino es un mandato que tenemos de no obligar a que
los ministerios de salud hagan e implementen algo en los cuales ellos mismo no estén convencidos.
(A pesar de que nosotros, digamos, no, es que...es por esto)...técnicamente usted lo puede
fundamentar, pero ellos terminan decidiendo a lo interno si lo implementan o no. Como el caso del
Concentrado de Strout en donde ya se está implementando y eso ha permitido que haya más
diagnóstico de Chagas agudo.
PR: También en nuestra reunión ayer con el Ing. Romero y la Dra. Gavidia nos enteramos de que El
Salvador ha reformado su sistema de salud en 2009, lo que coincidió con un informe de la OPS
sobre la atención primaria de salud integral y las Redes Integrales e Integradas de Servicios de
Salud. Y por eso estábamos pensando si la OPS también participó en esa reforma de manera de
asesoría o algo así?
(43:04)
VM: No sé si lo han leído pero este país en el año 2009 hubo un cambio de gobierno donde el
gobierno del partido oficial que era ARENA, Alianza Republicana Nacionalista (?), brazo derecho,
derechista, derecha, cambió...entró el FMLN, verdad, en el 2009 y con el cambio de gobierno
también hubo cambios en todas las instituciones del estado incluyendo el ministerio de salud. Llegó
la Ministra, que la puso el gobierno que la FMLN, la Dra. María Isabel Rodríguez...ella, dentro de
la visión que se tuvo como gobierno...una de las propuestas que el partido oficial vendió y que fue
aceptada por la población, de hecho ganó el frente, el FMLN, fue la reforma de salud. Con la
llegada de la Dra. María Isabel Rodríguez esta reforma de salud comenzó a tener mucho auge, y la
reforma de salud implicaba básicamente la creación de redes integradas...de las RIISS, redes
integradas en atención en salud, verdad? Y también de algo que se conoce como los ECOS, que son
los equipos comunitarios en salud familiar. Digamos que la logística es...este es El Salvador, toda la
mesa, 5 regiones de salud, 17 SIBASIs que están, es una unidad administrativa bajo de la región de
salud, abajo del ECO (? - SIBASI) hay unidades comunitarias en salud familiar, y abajdo de la
unidad comunitaria en salud familiar están los ECOS que están exactamente en la comunidad. Pero
todo esto, y el apoyo que se ha dado y se ha brindado para que esto pueda poder llegar a tener éxito
ha sido, gracias a ese apoyo a esa visión que se dio, la OPS brindó mucha asistencias y apoyo
técnico para la conceptualización de cómo la red debe de funcionar, y la red no solamente implica el
tema de referencia y retorno del paciente, sino también una serie de atenciones básicas que debe de
recibir a través del equipo comunitario en salud familiar, el ECO, la actualización de la ficha clínica
para la salud de la familia...también asimismo la necesidad de tener y de saber esas necesidades,
pero hay que recordar que cuando uno, como en ese caso, se llega hasta el nivel de la comunidad,
salen a flote un montón de necesidades. Y probablemente la capacidad institucional...somos un país
de renta media, en donde el producto interno bruto que se invierte en salud no es tan alto como en
otros paises, y eso también limita que el presupuesto que va destinado al ministerio de salud sea lo
suficiente para cubrir todas esas demandas y necesidades. Entonces hay muchas necesidades que se
han ido cubriendo poco a poco, y el tema de la extensión de cobertura de la atención a nivel de la
comunidad con la creación de los ECOS se ha cubierto. Pero no en todo el país todavía la reforma
ha llegado...hay lugares que han sido más exitosos que otros, pero también eso implica la necesidad
de contar con financimiento porque si usted va a tener un ECO en la comunidad, implica que debe
de contratar unos nuevos recursos: enfermera, médico, promotor de salud...entonces todas esas
necesidades...se ha visto la necesidad de contar con un financimiento, con un presupuesto que
permita que la reforma de salud tienda a incrementarse. No significa que lo que se ha hecho hasta el
momento sea malo, al contrario, ha sido muy beneficioso para la población. Sin embargo, todavía
vamos por ese camino pero no está todo el país aún cubierto con ECOS...aún usted puede entrar en
la página del ministerio de salud y ahí hay un documento básico que habla de el nivel del
funcionamiento de las RIISS.
PR: Sí, ya lo hemos revisado.
(47:03)
VM: Y ese documento le habla, cómo está la estructura, cómo funciona etc. y eso ha permitido que
también inclusive...a través de OPS o inclusive del mismo sistema de agencia de Naciones Unidas
haya en algún momento apoyado para que el financimiento en otras áreas también se pueda
permitir...porque el tema, por ejemplo de que un ECO pueda tener, encontrar un diagnóstico de
necesidades en la comunidad no solamente tiene que ver con salud...muchas veces son problemas
que no tienen vivienda, no tienen agua potable, no tienen un sanitario de poder ir a hacer sus
necesidades, y no sólo a salud le compete, está afuera del alcance de su mandato (como tan)...pero
sí ha sido importante.
PR: También ayar nos enteramos de que el programa de Chagas a veces hacen recomendaciones
para, por ejemplo, mejoras de las viviendas o las condiciones básicas, pero no sé si usted sabe, pero
realmente es posible para las comunidades seguir esas recomendaciones
(48:14)
VM: No siempre, no siempre. Actualmente, con la universidad de El Salvador había un proyecto de
ECOSALUD en donde estaba una Dra. __ __ (Abregu) creo es su apellido...en donde ellos tenían,
gestionaban unos fondos , y con esos fondos estuvieron en la zona de Verapaz, en el departamento
de San Vicente, trabajando en las mejoras de las paredes...principalmente lo que hacían era cerrar
las grietas, no? Para que el insecto no viviese ahí. Ellos...intervenciones que hicieron...nosotros
como OPS no hemos apoyado a este momento para que...mejora de viviendas...no es nuestra
fuerte...el tema de salud principalmente...mas sin embargo, el tema de la enfermedad de Chagas es
un tema que se quiere llevar inclusive como un apoyo para las alcaldías, ya que las alcaldías en los
programas que ellos ejecutan a nivel de las comunidades, ellos tienen un porcentaje que se llama el
Fondo de Desarrollo Local que (logra) el FISDL1 que es una institución que coordina con
COMURES que es la comunidad de alcaldes, de los 262 municipios, y son ellos a través de su
proyecto interno que pueden apoyar. Pero sí salud ha estado involucrado directamente en ver esas
necesidades, pero creemos que la recomendación y el trabajo en las comunidades sí ya es un apoyo
muy importante que se debe de ventilar exactamente a nivel de la comunidad...por eso es importante
que la experiencias exitosas que haya entre coordinación de alcaldía, comunidades, y control del
vector se puedan llevar a otro nivel...inclusive sistematizar y socializar para ver lo que hicieron y
cómo lo hicieron, lo que han obtenido...hay una experiencia muy importante en del departamento de
Usulután, un documento que estamos revisando con el Ing. Romero que creemos que ya para enero
va a estar listo para poderlo dar a conocer...en donde hubo una participación importante del alcalde,
verdad, y de su consejo en gestionar el control de la enfermedad de Chagas en el departamento de
Usulután. Entonces ese va a ser como un modelo que se pudiera utilizar en el futuro.
1
Fondo de Inversión Social para el Desarrollo Local
PR: Y otra cosa de esa reforma del sistema de salud. En su opinión, ha aumentado la participación
comunitaria a través de esa reforma?
(50:44)
VM: Sí, la respuesta es contundentemente sí. Ya que gracias a la reforma de salud ha permitido que
los comités de gestión local, eso es al nivel de comunidad, pueda desarrollarse, y pueda llevarse a
cabo. Eso implica una coordinación muy estrecha de la comunidad y su organización interna con el
ECO, con la UCSF2 inclusive con todo lo que es el esquema de la red integral e integrada de salud,
con la RIISS...y el trabajo ha sido muy importante porque eso ha permitido también que muchas de
las intervenciones que la unidad de salud tiene, o la unidad comunitaria de salud tiene, vayan de la
mano con las necesidades de la comunidad. Claro, no siempre se puede dar solución a todos los
problemas...comunidades que posiblemente han estado abandonadas por mucho tiempo tienen una
cantidad de necesidades en donde salud difícilmente va a poder llegar a construir casas, difícilmente
va a llegar construir puentes, tampoco calles porque no le corresponde, y es ahí donde la integración
con otras instituciones del estado u otro organismo es donde tienen un papel muy importante
PR: También quisiéramos saber cuáles son las ventajas de las RIISS en comparación con el sistema
de antes...o sea, cuáles problemas eran relacionados a la fragmentación de los servicios de salud de
antes?
(52:17)
VM: Fíjense que fundamentalmente el tema tiene que ver, primero con el acceso de la población al
servicio de salud...ese es un...antes no existía. La persona tenía que ir a la unidad de salud cuando
estaba enferma, ahora la unidad de salud al persona...va a las viviendas...hace la visita domiciliar,
diagnostican ahí, tratan ahí, y si hay una necesidad de referir, refiere. Porque cada uno tiene su nivel
de competencia, y de atención...antes eso no existía...dos: antes, usted, la persona iba, le daba una
referencia para un nivel de atención mayor, y usted no sabía si la persona podía asistir al otro lugar
a tratar su salud, su enfermedad o su caso, ni tampoco sabía si de este otro lugar la persona llegaba
con unas indicaciones a su casa. Ahora, todo eso, por lo menos donde la reforma se ha dado, a
través de las RIISS se coordina para disponibilidad de medicamentos, disponibilidad inclusive de
imunizaciones...medicamentos principalmente, seguimiento de otro tipo de...embarazadas por
ejemplo. Entonces el nivel que actualmente se tiene ha mejorado importantemente pero, como le
2
Unidad Comunitaria de Salud Familiar
repito, si se está más cerca de la comunidad o las personas, hay más necesidades que se
diagnostican. El tema nutricional por ejemplo...que se tenía antes...hay más de nutrición
posiblemente que lo que antes se pensaba que había pero porque ahora se está diagnosticando, se
está haciendo al nivel comunitario mayor trabajo...entonces la reforma también ha (colaborado)
muy importante en la coordinación con otras instituciones, ONGs, seguridad social, bienestar
magisterial, todas estas instituciones que forman parte del sistema nacional de salud. Esa
coordinación ha hecho, como ya le mencioné, que las intervenciones de todas esas otras
instituciones puedan sumarse y llegar a un problema de tal manera que si la institución X más el
ministerio de salud...si esta institución iba a coordinar desparasitación, hacerlo junto con el
ministerio de salud...porque los que no curen, el ministerio de salud los pueden cubrir los demás.
Con el tema del seguro social, tambíen apoyar, las zonas de intervención que ellos tienen,
recordando que el seguro social sólo asiste a las personas que estén aseguradas...pero es importante
saber que si esta persona deja de trabajar o de laborar ya no es beneficiado del seguro social, y por
lo tanto si tiene una enfermedad crónica o un seguimiento especial...que queda a dar seguimiento,
esta persona ya no (verá?) el seguro social, pero hay el ministerio de salud que termina
(decidiendo/haciendo) el ministerio de salud quién asume la responsabilidad del seguimiento al
tratamiento. Principalmente enfermedades crónicas de larga duración como (diabetes mellitus),
hipertensión arterial, y problemas oncológicos, cánceres o de otras índoles...por eso es importante
que ahora, a través de la reforma, las instituciones...las otras instituciones de salud se coordinen.
Hay limitantes siempre como en todo, hay necesidades de mejorar como en todo, pero creemos que
va por el camino.
PR: También tenemos una pregunta sobre el inicio del programa de Chagas y también los objetivos
para el futuro.
VM: Sí. Yo querría preguntarle...porque yo tengo una reunión a las 12:30 en el ministerio de
salud...pero querría preguntar si habrá posibilidad de continuar mañana?
PR: Sí, pero de hecho sólo tenemos dos preguntas cortas...
VM: Ah OK, está bien...yo...está bien.
PR: Perfecto. Sólo quisiéramos saber si había condiciones específicas que los paises de
Centroamérica tenían que cumplir para obtener el apoyo técnico de la OPS? O sea, había una
manera específica de organizar el sistema de salud que tenían que hacer?
(56:05)
VM: Ah OK. Interesante esa pregunta. La respuesta es: No. No hay condiciones específicas en el
sentido de que...hay que recordar que la Organización Mundial de la Salud está conformada...es una
institución...pero lo que ellos prácticamente operativizan o ejecutan son mandatos que son tomados
a través de la asambleas mundiales de la salud. Y en la asamblea mundial de la salud...son los
ministros de salud y/o delegados los que conforman esa asamblea mundial de la salud y son los que
terminan tomando decisiones sobre normativas de toda las índoles que tengan que ver con la salud.
Significa que, a la hora que todos los ministros de salud o todas las personas delegadas del país
aprueban, la OMS operativiza a través de la OPS, y la OPS coordina con el ministerio de salud.
Pero este ministerio de salud, la cabeza del ministerio de salud que es el ministro de salud ya fue
acá [asamblea mundial?]. Por lo tanto el que la OPS quiera implementar en algunos paises,
afortunadamente, viene por un mandato que ya fue previamente acordado con los ministros de
salud. Eso significa de que las condiciones de cada país, independientemente de su estado social,
político, económico, verdad, se implementa, y es por ello que del avance que se tiene...en algunos
temas hay más avances en otros hay menos. El tema de la mortalidad materna, por ejemplo que
hemos tenido un avance importante, y ya las demás enfermedades que le comenté...entonces es por
ello que no se ve [condiciones?] además hay otra cosa. El Banco de Cooperación de la OPS se da
siempre a través, no solamente como OPS, sino de todas las agencias, de las 11 agencias de
Naciones Unidas, establecen un convenio, una alianza con relaciones (integrales) con el ministro de
gobernación y a través de ello firman un acuerdo de cooperación técnica. Y en ese acuerdo de
cooperación técnica va el tema de la (invitación), desarrollo local, seguridad, salud, alimentación,
gestión de riesgo...entonces y en ese marco __ de la cooperación de los paises que nosotros también
__ __ (enumerar). Entonces las condiciones las (pone) el gobierno...el apoyo técnico prácticamente
lo pone la OPS y algún financiamiento que tenga para trabajar en esas áreas específicas.
PR: Perfecto. Al final sólo quisiéramos saber...porque hemos leído que entre 2011 y el 2015 era un
objetivo eliminar la infestación domiciliar de la T. dimidiata pero hemos leído que eso
probablemente no es posible ya que es una chinche autóctona y también vive en la naturaleza. Pero
quisiéramos saber qué podría ser un objetivo realístico [realista?]?
(58:56)
VM: Lo que sucede...es cierto que estaba como una meta, como un objetivo bien importante al
2015. De hecho, el objetivo 6 de los ODM, los Objetivos de Desarrollo el Milenio que ahora se han
transformado en Objetivos de Desarrollo Sostenible, los ODS, obligaba que al 2015 esa meta se
pudiera ver cumplido. Mas sin embargo, en el caso de El Salvador no se ha cumplido...tal vez en el
marco de las ODS habría que trabajar...porque es un reto importante, como usted ya lo mencionó,
que es una chinche autóctona. Y mientras las condiciones socioeconómicas o medioambientales de
la propia vivienda no se mejoren, difícilmente vamos a poder llegar a eliminarla. Pero hay que
tomar en cuenta también de que muchas veces nos enfocamos a la vivienda. ”La vivienda, la
vivienda, la vivienda”. Pero hay que recordar que esta chinche también generalmente, si no está en
la vivienda, está alrededor en la parte peridomiciliar, y que también hay otros huespedes
intermediarios que tienen, no solamente es las aves, tenemos perros también, tenemos animales
salvajes también e inclusive hay un proyecto...hay una investigación que nosotros propusimos al
Ing. Romero para este año...ver si era posible poder evaluar la importancia o no del perro...como en
la mayoría de viviendas hay uno o más perros...más en el área rual. Entonces la importancia del
perro como un huesped intermediario de la enfermedad de Chagas. Porque muchas veces se ha
encontrado...no la chinche en la casa, sino afuera pero que tanto el perro puede llegar a tener una
importancia en esto. El perro y otros animales. En Guatemala se hizo un estudio donde, si no
recuerdo, era el 30, 40 % donde los perros estaban infectados. Y en ello en fase aguda, verdad.
Entonces...por el trypanosoma. Entonces vamos a ver si para este año podemos apoyar al Ing. en
eso. Pero sí, sería esa [un objetivo para el futuro].
PR: Bueno, al final sólo quisiéramos saber si hay algo importante sobre lo que no hemos
preguntado o hay algo que usted desea añadir?
(1:01:20)
VM: Quizás preguntar, como el Ing. me comentó, que era una tesis – sobre qué es la tesis?
PR: Sobre los programas de El Salvador, Honduras...Centroamérica. También hemos hecho una
entrevista con un representante de los Médicos Sin Fronteras que están en Bolivia, y más que nada
nosotros quisiéramos buscar...como buenas prácticas o algo que programas en el futuro pueden
utilizar...
(1:01:55)
VM: Habla de buenas prácticas, JICA recién....hay un CD que hicieron sobre buenas prácticas en
Centroamérica fue....
PR: Sí sí, tenemos el informe. Bueno, entonces sólo queremos agradecerle mucho su tiempo y
también queremos mencionar que la investigación sólo sirve para la tesis, y no tenemos la intención
de publicarla, pero si vamos a tener la oportunidad, vamos a volver a pedirle su consentimiento.
VM: Claro. Recuerde que las tesis que no se publican, no sirven. Entonces tiene que publicarse.
PR: Por eso vamos a...si tenemos la oportunidad de hacerlo vamos a pedirle su contentimiento.
VM: Sí, sí con mucho gusto. Y caso necesiten algo más que nos haya quedado, siéntanse con la
libertad de preguntarme. Ahí está...el Ing. Romero me copió el correo de ustedes...
PR: Ah OK. Porque de hecho tratamos de enviarle un correo, pero...
VM: Es que el correo que tenía estaba equivocado. Pero en el último correo que él me envió que les
copió a ustedes...ahí ese correo funciona...pero sí disculpe por la hora pero yo tengo que estar a las
12:30 pero por eso mencionaba que si necesitan algo más o si desean conversar otro tema, con
mucho gusto puedo...
Ken Hashimoto interview
1 t 16.30 – Us: Firstly we would like you to tell us about the tasks and functions you
have carried out in the Chagas program in both El Salvador and the Central
American region?
Ken: My most recent role in Central America has been as a regional advisor where I
covered El Salvador, Honduras, Guatemala, and Nicaragua. But Nicaragua maybe
only a couple of times a year because they had a project there from 2009-2014
whereas the other three projects ended in 2011-2012. So I kind of followed up on the
activities so that the projects sustainability would remain. Not as perfect as we would
expect but as much as possible. That’s one, the was to pick up best practices from
these countries so at leas they have recipes, the knowledge, so that when they have
difficulties or challenges coming across in the future they have the ideas and now they
know that these ideas or experiences came from themselves so the other was a
confidence building process. So one was knowledge and the other was confidence
building so that they can continue fighting and realising the activities. That was the
two purposes of out follow-up phase or my role as a regional advisor and within the
technical cooperational follow-up to improve sustainability we focused on the
pinpoint activities: one was the biannual evaluations. Every country had their
biannual meetings where the departmental technicians presented the advances as well
as the challenges and difficulties and then they had discussions to see the better
solutions etc. That was one, the other was to inject the central level by organising a
regular meeting where different heads of the program was represented as a committee
to monitor the central program, the national program. Maybe Eduardo told you about
this committee in El Salvador? But we organised this in each country to make sure
that hey had this. Because the national program is the top of the program or the
command. Technically. If they did not have anyone who could give feedback to them
they can get lost or they won’t realise what position they could be in. So that was the
purpose and the two main activities that I followed up to give more sustainability to
the project.
1 t 11.05 – Us: The first question is a bit of a follow-up from our interview with Kota.
He mentioned that in Nicaragua one of the problems surrounding the Chagas
program was the lack of priority and the lack of political will within the system. How
do you see this in El Salvador and in the other countries in Central America where
you have you experience?
Ken: For being a neglected tropical disease when you first start they say ‘we don’t
have that problem’. They say that because they don’t have the data to show that this is
a problem. No data, no problem, which is the initial approach. Their mind-set, you
can say. Luckily we had two positive news. One was that JICA had an investigation
project in the 1990’s in Guatemala so they proved with data that there was a problem
as well as the De Valle university in Guatemala, which was part of CDC a Central
American unit that showed that there was an entomological issue of Chagas disease.
So that kind of data was published by research institutes. The other was political will,
not internally created in the country, but internationally. That was IPCA which was
organised in 1997 by what we call ECLAT, which is organised by Chris Scofield, the
entomologist, and some South American guys who had been working in South
America since the 1960’s. So they had this experience and they had the international
network to organise the South American model in Central America. So they had this
know-how of how to raise more political awareness and political will internationally
of course involving PAHO and WHO. So ones they knew that they had to make the
MoH’s sign the regional commitment or contract through RESSCAD. RESSCAD is
the Central American and Dominican Republic health summit. That was the moment
they kind of made concrete commitments official at the regional level but breaking it
down to the national level so that they had no excuse [for not acting]. That ‘look we
didn’t know’, they could not say that officially. Of course that is very initial steps but
to really implement a policy is another step and that is where we in JICA played a
role.
1 t 7.10 – Us: But you said there was still a regional reluctance or lack of political
will how is that exactly again?
Kota: Lack of political will at the regional level. There are two stages I can think of:
one is on paper and here you have to convince all the minsters and actors like WHO
and all that and that was helped by the South American experts or the ECLAT, the
scientific group. The other is really implementing this signed document in each
country lead by the MoH, which is a different challenge.
1 t 6.10 – Us: I was wondering, in your experience, how Chagas disease was
prioritised in El Salvador compared to other health issues? Is it a big issue compared
to Dengue, Malaria etc. or is it a smaller priority that these diseases?
Ken: Yeah that’s a great question. Each of the CA countries had difficulties in
prioritising the Chagas disease but each country is different. El Salvador was lucky in
a way and maybe the luckiest of them all in that they had a scientific backbone. In
1913, if I remember correctly, there was a scientist named Segovia who discovered
Chagas disease and Segovia had a high recognition at the national university in El
Salvador. He taught all the medical students who became medical doctors of the MoH
and also did you meet the doctor Mr. Rafael Cedillos? (we answer no) But he of
course was a student or students’ student at that time. He realised the importance of
Chagas disease and he was a PAHO consultant as well since the 1950’s so each key
person included Chagas as a priority. Not directly but as an additional activity of
Malaria control. So doctor Cedillos did not have a budget only for Chagas but he
utilized Malaria… because Malaria had big budgets at that time but he knew that it
[Chagas] was an important problem back then. So he began there. And then after that
because of the internal civil conflict they could not continue as much as they wanted.
Still the DNA continued in national universities and the most recent case was ehhh…
the minister of health, do you know the lady who was 93 years old… Marie
Rodriguez?
1 t 2.25 – Us: Ahh yes, Romero told us about her in the interview.
Ken: Yeah, she was one of the students of Segovia. That also helped. She was of
course a professor at the national university. All this connecting the dots - connecting
the important people raise priority. That was the case of El Salvador. Of course it is
quite similar in other countries but the key persons helped us. Eduardo [Romero] of
course is a key person, no doubt. So practically as a national program or in
comparison to others like Malaria and Dengue it is not officially categorized as a high
high priority all the time because the only effect is on the impoverished population. It
is not like Dengue in the cities where politicians’ families or relatives are killed or
affected. But still it is a challenge… but that is the reason why Chagas raised its
priority in these countries.
1 t 00.50 – Us: Moving on about JICA’s involvement and where they were involved.
We have read that JICA has mainly been involved in the chemical control, the
entomological investigation and surveillance, and the Information, Education, and
Communication (IEC) strategy. Why was this division of responsibilities chosen in El
Salvador?
Ken: It applies to other countries as well. As I mentioned it was difficult to a policy
for the MoH. They knew the goal, they shared a goal and they had kind of ideas of
what they had to do because of the South American guys [ECLAT] had established
control methods but implementing it is another matter. Like putting theory into
practice in an organisation where you already have routine activities for Malaria and
Dengue among other disease control programs. So our input was for one to change the
systems within the MoH and the second was internal management. How do you make
people behave or work differently? In addition to that we donated vehicles and
insecticides where they did not have start up budgets and maybe additionally more
later on if needed. So our role was first to break down the policy into practice and
integrating all this theory into their context, the local context, but not by doing it
ourselves. Making sure that it is their problem and their program so that the
ownership remains in them. Now of course that is very important and we intended…
it is easier said than done. Especially at the initial point, which we call preparatory
and attack phase. That’s… we had to act differently. That phase was top-down
management. If you talk about the central or national program and the regional or
departmental program… because of decentralisation the managerial capacity or the
command line was weakened and that made the mentality and the technicality weren’t
shared as much as they should have been. Well, what we had to do was to make sure
they had good communication from top down. Fore sure also bottom-up but
technically the program had to be implemented nationally and be passed on to the
operational level, which is the district or departmental level. So that was the primary
purpose when we started the project. If I remember they didn’t even have a national
manual or guideline to implement so we started at the central program and then we
made sure that the technical guideline was passed on to the operational level. Then
once we created the model… in the case of El Salvador it was… because they had
different levels not just the national and departmental. They had that regional in
between so they made sure that they were monitored. The regional guys were the
monitors of the departmental operational level, the technicians. So including that kind
of organizational reality we established the model and then extended it to other
departments so that the national coverage was established… achieved. So that was the
technical side. Of course the management is another… because capacity required at
the national level is different from the departmental level so JICA send volunteers to
the departmental levels and that’s where they monitored the managerial side. It’s
simple things like planning… what are we going to do this year in terms of Chagas
control? So then to break it down to monthly and daily activities and can we really do
it if we really follow the plans? Or if you are not following them what is going on? If
it is the plan, it’s the activity itself, or resources, or dengue or what is happening. That
kind of monitoring and improving. So how can we improve it? – do they think
themselves. And of course the feedback to the central level and sharing the
experiences with other departments etc. So that was another activity we wanted to
reinforce, the managerial capacity at the local level. That was the attack phase. For the
surveillance phase it was more bottom-up because once we had the operational
personal trained we new that the problem was getting so much more than Chagas
disease or epidemiology. Listen its major and taking up their time and efforts at the
local level. And of course there were changes in the epidemiological reality, some
areas had more problems than others and we knew that because of this irregular
decentralisation. Not all health centres had the same capacity of people to respond to
Chagas problem, vector reports etc. so we let them think how they could solve their
problems and organise their team and managerial side. Because if we say… we may
show and share what we have got to do but we left them with how. That is what they
think, how are they going to achieve it? So that was our approach. Of course some did
good and others didn’t but that was good. What’s important was the shared
experiences and made sure that they think themselves. How are they going to get over
each situation at the local level?
51.40 – Us: In choosing what areas to focus on, in choosing where you should assist,
were the different levels of the program part of this process?
Ken: Yes and no. It comes down to a coupe of… maybe two of three points. One is
that it depends on the managerial capacity of the departmental coordinator for vector
control programs. If that guy is highly interested and knows what to do, how to deal
with his resources… of course they always have lots of activities going on: dengue,
malaria etc but if he knew what he had to do and with what resources, and if he didn’t
have [resources] then know how to find them then it was completed. However if the
managerial capacity of the departmental coordinator was not optimum or low then it
was difficult. When the dengue epidemic came it was all panic… hehe… but El
Salvador had good regional supervisors… monitors… and they had experiences.
48.55 – Us: Subsequently, after the termination of the project by JICA… I don’t know
how much inside you have as of right now in the Chagas program but do you sense
they were well equipped to carry on the tasks, especially the ones assisted by JICA
and PAHO as well?
Ken: In El Salvador?
Us: Yes.
Ken: Yeah… yes to some extent. This is kind of a yes and no answer as well (both yes
and no). We believe that they have the capacities now to handle the disease control
themselves. In that sense they should be able to respond to vector infestations at the
local level. Now it again comes down to the individual capacity, local capacity to
respond. In health centres where they have very responsible and interested personal
they do give response. One is that the community is more empowered and they how
to claim to the health centre. That is very important. The other is that the health centre
personal know how to respond to the demand or the vector problem. Where that is
working, yes I am sure that is still working as a good surveillance system. However, if
that cycle is damaged or broken because of personal change… that changes local
leadership and also the organisational culture so to say. That may be affected but then
again that is the responsibility of the supervisors to keep raising the motivation and
making sure that the data and information is circulating from the bottom and up and
giving feedback top-down. So sure some parts are working and some parts are not to
the optimal level.
45.45 – Us: We know that El Salvador is one of the places where the have the best
capacity to carry out the tests, the blood tests, and they have the laboratories in all of
the country where you can carry out the serological tests. Bu apart from that how do
you rate El Salvador compared to the other CA countries in terms of controlling
Chagas disease? And also the priority?
Ken: You know, in general, the MoH of El Salvador has the highest capacity for
planning, management, as well as monitoring. That’s what I realised working in
Guatemala and Honduras. One is their mentality. El Salvadorians are more serious. I
am not saying that the others are not serious but they are often called the Japanese in
CA. Yeah, I am sure there are a lot of problems including corruption but I see less of
that kind of atmosphere and moves in El Salvador. That is one big difference. The
other is… they have more resources and infrastructure in terms of health centres and
teams… like vector control programs. As well as health promoters who visit each
village every month, 2 months, or 3 months, depending on the problems. But in
addition to that capacity of the MoH, resources, and the mentality etc. it is the
geographic advantage they have. It is all accessible. When I go to El Salvador I rarely
stay in a departmental capital. I come back to San Salvador in one day. In other
countries that is impossible. So that’s… not just from San Salvador to the department
but the departments as well… they can travel to the rural areas and come back in one
day so that is a great advantage. As well as for the population to go to the local health
centre.
42.15 – Us: So its both infrastructure and size as well?
Ken: Yeah accessibility… yeah size… of course. Many Honduran, Nicaraguan, and
Guatemalan go to Salvadorian health centres to get better health services if they live
in the border areas.
41.35 – Us: You mentioned the health infrastructure with health promoters and
municipal health centres. We were also wondering… when we were in El Salvador we
heard about the health reform of the health system in 2009 and onwards. In you
opinion how did this health reform affect the Chagas program? Did it make the
Chagas program easier?
Ken: Yes and no again… hehe. Yes in that it included Chagas as one of the criteria…
maybe not criteria but as a basic need. If the characteristic of the house was like…
risky for chagas vectors to infest (he means in the house is in risk of being infested)
then they had to make sure of certain visits… I don’t remember in detail but they had
to pay more attention because it meant poverty, which was one of their priorities and
now that’s a left wing/communist kind of mentality or idea that they have for this
package, right. So that helped. But on the other hand if the health reform itself is
effective or not is another matter because… there are rumours and one is that people
who compose a team, like a rural visit team, they don’t really know what to do. They
are a team of communists. Of course… I mean they have interest in community work
but they have no experience. They are new. So even if it is all written in paper they
don’t have the experience and knowledge… it’s difficult to provide services. Not only
Chagas but in all others. So that was one worry. The other was sustainability. I mean,
once you start visiting each village providing health education, services, and…
completely… the population become dependant. And of course it is very expensive
for the MoH to provide that kind of service throughout the country. So the
sustainability… it hasn’t got and exit so I don’t know of that strategy itself is going to
be effective and sustainable.
37.45 – Us: Just going a bit back to the whole best practice – Eduardo mentioned that
besides from these point that pointed out in the best practice of what was implemented
in El Salvador there were also some initiatives left out. You know, they were done but
not written down. Which were these? Do you remember that?
Ken: Uhh… We discussed a lot and there were like some fifty practices and we sat
down to make 22. I don’t remember…
36.35 – Us: So as we mentioned in the beginning of the interview one of the things we
are focussing on in our thesis is this difference between vertical and horizontal
programs. And we were wondering first of all what the reason was for choosing as
single specific disease beginning in Guatemala and then transferring the experiences
to the other countries. What was the reason for focussing on a single disease instead
of trying to work more broadly with the whole health system?
Ken: When the program started in Guatemala back in 2000… in general horizontal
and vertical issue wasn’t big in global health or in that time international health. And
nobody really cared in that sense about the negative side of vertical programs. In fact
they had always worked vertically in their countries as well. Now in Guatemala, in all
Central American countries in 1990, the policy for health reform has passed and then
they started kind of changing more horizontal, decentralising. Now back then the
decentralisation still was deconcentration (not sure what he means with this word.
Maybe that it was not consistent.). So what they had, all these resources including
personal, human resources, equipment etc. at the central level was passed to the
departmental level. But still the structure was the same, pretty much. They had the
resources concentrated, or the departmental capital, under the same operational
personal to villages and back and forth. So that was the kind of situation [back] then.
So, yeah it was vertical and that was natural for us. Also we knew that Malaria was
established… Malaria control… as well as dengue. Well, you couldn’t say that it was
established but they were working strongly. Also on ___ ____ ____ almost ended so
they established but Chagas wasn’t there as a program. Mind you, this money is still
not there. Well it was in the beginning but… So we thought as an international
corporation that it is good to start where they don’t have enough capacity instead of
where they already have.
33.05 – Us: Actually you just mentioned a bit about it earlier when you pointed out
that El Salvador was the country in Central America that had the least problems with
corruption. Kota he talked about it as well and he actually talked about it as an
argument or… as something that made it difficult to have the broader approach to
health intervention. But in the context of El Salvador, if corruption is not really and
issue what do you see as the barriers you can run into in El Salvador? In
implementing both vertical and horizontal. It’s not just one but in making these
interventions.
Ken: There are several challenges there. Starting generally one is violence. It’s getting
more and more difficult to get to villages. I mean urban areas it is difficult to work
with. In rural areas it was easier back then, 15 years ago. But still they had Maras,
gangs creating their own territories. That’s a challenge for El Salvador. One. The
other is the nature or behaviour of triatoma dimidiate. It’s harder to control there than
in Guatemala and Honduras. We suspect that because they have very dense residential
areas they have practically no peri-domestic areas so if you get the insects out of the
house they go to neighbours instead of going to like… chicken house or corrals. Of
course for the bugs it is easier for them to live in dense areas, right, because they have
more accessible food. So that can be another challenge for El Salvador in general.
Now… talking about the system, the health system challenge, it is more about…
difficult to say but… independence of the population… I mean in other countries
there are health volunteers in all the communities working strongly organising
themselves and to work with the MoH. Like a system of the MoH (I think!). That
creates more autonomy, more independence within the community. The case of El
Salvador, because they are more accessible directly to the health centres (health
centres are close) and they have more personal visiting their villages… that can create
more dependence for the population.
28.20 – Us: Kota also mentioned the thing about if you want to support a whole
health system horizontally you give the money but without giving certain prescriptions
about exactly what the money is being used for and he mentioned that it can be a
problem because you need to have a certain amount of control with the money in
order to know if the money is going to be spend in an efficient way. Would you
consider this as sort of a barrier for making more horizontally oriented health
interventions?
Ken: It comes down to the priority settings at the departmental or more operational
level and then if the same amount money or the budget is available it is really up to
the local personal… local leadership. So if they consider Chagas as a high priority,
yes they will use them. But the challenge comes to the surveillance phase now
because the problem is getting smaller and smaller and less impressive. So it’s going
to be difficult to…
26.35 – Us: One more thing that we learned in El Salvador was the fact that now a
100% of blood donors are being screened and that earlier only a certain percentage
were being screened. And we were wondering if this practice is something that started
with the Chagas program or if the Chagas program kind of induced this kind of
practice?
Ken: It was part of the… one of the goals of IPCA when it was established in 1997.
Back then, I don’t remember if El Salvador had 100% coverage at the blood bank for
Chagas screening but it was another effort. Of course we monitored biannual
meetings, evaluation meetings. We prepared space for presentation for the blood bank
so they knew what was happening, improving, achieving etc. So yeah, we certainly
(maybe) monitoring. It was the efforts by the blood banks at the national as well as
the regional, the Central American level. I think I mentioned in my book Gabriel
Schmunis, he was like the coordinator for Central- and South American Chagas
disease control for PAHO in Washington but he was a blood bank guy. He really
made sure of the screening coverage as well as the quality. He kept asking ‘what is
happening? You are really sure you are doing good? Show us data and let’s show
every countries advance’. So that kind of follow up and pressure he established from
the top level, from the regional PAHO level.
24.05 – Us: Another thing we learned from the interview in El Salvador was that
there hasn’t really been any collaboration with other agencies or actors that are
outside the health system. How would see the possibilities of cooperating with NGO’s
or religious organisations in El Salvador. Could anything be gained from that in that
specific context?
Ken: Yes I think they have done so at the operational level. Fx. With the minster of
education they worked strongly from bottom up. I mean firstly between the
operational personal and the schoolteachers and then going up to the departmental,
regional, and national level. I think that was one big work and they now have like a
national consensus to work with. But that is difficult to establish with any other NGOs
and churches maybe but they have been working… like… once you go to the
communities each community have their different network of influence. So the leader
may be like a priest for that area particularly or maybe like a soccer team captain or
coach for the other area. Or maybe a women’s club leader, like a big grandmother of
the area. Maybe in a small village it is all family and relatives, blood related, so it is
so different. They have been working… we don’t mention it because it is impossible
to note who is the key organisation in each context or in each village because it’s too
much data. It’s more in the implicit knowledge. So I do know that they have been
working with different organisations, not systematically as with the Ministry of
Education.
21.15 – Us: You said that there is a question about the sustainability. Actually,
generally it is a question surrounding the whole program. We know that you have
written a lot about the critique of using the goal of elimination. Is this a problem in
relation to funds? Will it be a problem for the program in the long run to maintain a
level of service and a level of intervention?
Ken: At the national level it’s… there are advantages and disadvantages. Once you set
a goal of elimination… I mean you are kind of committed fully. You know you have
goal to end… you that this activity is going to end once you achieve that target so you
can invite more actors… stakeholders from outside as well as inside. And then you
work fully on it. That is good in terms of creating momentums or working with
donors with short goals interests. But once you are at the local level and working with
people, the population, and know the reality that… you know with the dimidiata you
are going to have to live with it. It’s not going to end. I mean you can minimize it but
end end is going to be difficult. And then it becomes tricky. You can’t deceive people,
you can’t lie to the locals. And then also programming becomes different…
programming of the activities. You really have to integrate… you have to realty
minimize the work of the chagas disease control so that the locals can work within
their working hours and budgets etc. and keep maintaining the problem at the minimal
level. With elimination efforts and projects you are condensing the efforts and
budgets etc. but not leaving for the latter.
18.00 – Us: During out visit to El Salvador both Eduardo and Mirna and also some
people in a municipal health centre in San Pablo Chacachico they told us that one of
the things that had been most helpful to them was the support for the promotional
activities. But that since JICA has terminated its part of the projects there has been a
less funds available for these activities and were wondering what you thoughts are on
this? How could something like that be transferred without the funds? Can they
actually continue with this or is more political will necessary in order to have enough
funds for such activities?
Ken: It’s… after all we believe that it is the country’s will and of course not just the
national level but the local political will as well, who really want to deal with this
Chagas program. Of course we do hope they continue fighting as much as they can
and make sure that their population is safe and healthy, liberated from chagas disease
infection. Of course we hope that. Having said that we do respect that there are other
health problems that they have to deal with so we don’t enforce. We do respect their
decisions. But at least they have the knowledge how they can come over (overcome)
[this problem] that’s one of the reasons why we made this best practice… guidebook.
It’s there and they know how to create promotion material etc. So it comes down
again to leadership of the regional and the national level. That’s one of the reasons we
created or established [a] committee at the national level. We have to inject the
national program now and again. I don’t know to what extent the national committee
is working because of personal change etc. I mean that committee has to be injected
again by IPCA… regional level or regional efforts. So it comes down to PAHO’s
leadership as well.
14.35 – Us: We have been discussing, and we mentioned to earlier, the thing that this
program could be considered a vertical program. But we have talked about that there
has actually been some horizontal aspects of this program giving the fact that some of
the things this program has done: the management, the communication improvement,
the integration between different disciplines and the use of data entries are things that
can be used more broadly. So this also represents a horizontal benefit. But we were
also wondering, in you opinion, if the chagas program in other ways has strengthened
the health system more generally?
Ken: Yes it is possible because what we tried to do was not implement chagas disease
[control] itself but to make sure that the local health service provided good care
including chagas disease. More concretely what we wanted to do was to reduce the
workload. Not just for chagas… if you really want to work with chagas first you have
to reduce the workload. That is improving the management. Once they have achieved
that, once they have managed to deal better with everyday tasks or control of other
diseases then we deal better with chagas disease routine activities. So that was a kind
of mentality… lets work less for more effect. So we worked with GIS fx… how we
map problems. Not for chagas but we can use this for Malaria so lets do this. Lets do
that so we can identify where the problem was. And also time scheduling. Show me
you calendar, show me your schedule… this is going to be difficult, right… fx
Monday morning is going to be difficult to work if anything. You have a meeting;
you have a coordination meeting… leave it there for now, the Friday afternoon. All
that we discussed. Why don’t we meet every month or two month with the local
personal to monitor, not just for chagas but in general and see what we can do here.
So that was kind of (says a word I don’t get) general management. I don’t know
whether to call it horizontal or not but what I mean is that we didn’t work just for
chagas we did improve health service management in general.
11.00 – Us: In our interview with Kota he mentioned the livelihood approach with the
improvement of living conditions as a project in Nicaragua. He pointed to that it has
great potential but it’s very expensive and there are certain challenges in making it
work nationally. What are you thoughts on that approach and do you think it would
be feasible to use that in El Salvador?
Ken: They have been using it in some areas and we have… maybe you have come
across Carlota Monroy of Guatemala, San Carlos University of Guatemala. She and
her team established this method of improving walls and floors using local materials.
That was the technique Nicaragua implemented. That workshop was carried out in El
Salvador as well so they have the kind of knowledge and they share the concept as
well as the technology and methods. This livelihood improvement is a bit tricky in the
way that it falls into like a blind spot of older sectors. Fx to improve your walls, floors
and tighty up your rooms and etc. Whose responsibility is it? Of course operational
personal of the MoH go to the villages and give them advice. Look I mean… this is
what you have got to do. This is knowhow, this is the leaflets – you can see and study.
But when it comes to taking action it is kind of… they (operational teams) don’t have
much time and don’t have the capacity to organise the activities including materials.
Maybe they don’t have enough materials, sand or other resources. Tools to mix sand
etc. They really have to have local leadership there. Maybe it is the municipality’s
responsibility to make sure they have good living conditions but to what extent they
are interested is a different matter. Of course it is going to work but you really have to
have local leadership… one is from the community side the other is from the
institutional side. But with the MoH it really depends on the interest of the local
health facility as well as the municipality.
07.15 – Us: Finally we want to ask you if there is anything important you feel we have
left out? Something we have not asked you or maybe something you would like to
add?
Ken: Yeah maybe one thing… let me share one thing. You can work with chagas
differently from dengue and malaria. Not just because they have been established but
the transmission speed was different. With dengue you have react quickly – it is a
matter of hours or days. I mean, that is the pressure you usually have to react. With
chagas if you are bitten you don’t die in a week. Of course you have to make sure that
the patient does not develop symptoms etc. But we have time there to think and react.
It’s an advantage as well as a disadvantage but once it comes like a quick response
actions it is difficult to improve. Like we capture routinary and more show that we are
reacting to the epidemic etc. With chagas we had the time… look… How can we
better respond with limited resources, limited time. Because no rules were hardly
written and we could become (be) more creative in organising the response.
04.50 – Us: You are saying there are pros and cons but that was mainly pros I guess.
But on the con side can it be difficult to get the political support and the financial
support when there is time to act? Not only in the attack phase but also in the
chronicle.
Ken: Yeah, exactly. That is one of the reasons why maybe that… we were not
specialists for vector control to start with. The Japanese side. We had worked more on
the managerial side but we were not experts in management either. What you really
need with this work is more common sense. It’s nothing special… and the ability to
communicate with the locals. That’s what we found.
Kota interview
(The points of time are backwards)
57.00 – Us: So firstly we would like to know, what has you function been in
Nicaragua and what are you experiences so far?
Kota: Okay, so I worked in Nicaragua as a JICA expert, as a country level expert.
You have contacted Ken Hashimoto, right? Ken worked as a regional advisor whereas
I was in only working with Nicaragua. We started the project in 2009 and the project
finished in 2014 and I worked there for about four years with the MoH of Nicaragua. I
lived in Esteri (don’t know if spelled right) and I worked close with the local health
staff: the vector control staff, medical staff (NACIS), and sometimes community
health volunteer. So my role was mainly to cover the technical part and to promote
local staff capacities to cope with the Chagas disease. The first thing we did was to
conduct an entomological and serological survey to understand to what extent Chagas
was prevalent in Nicaragua and then based on that baseline survey we programmed a
large scaled spraying program to spray the dwellings. And we confirmed that the
vectors that are __ ___ ___. Then we tried to introduce what we call the vector survey
and response system and this survey system should be sustainable because we cannot
eliminate the vectors, so we asked for community participation as well.
54.20 – Us: Prior to you experience in Nicaragua do you have any other experiences
with health interventions?
Kota: The spraying program was completely managed in a vertical manner. We got
special funds from the main budget of the Nicaraguan MoH and we hired the sprayers
only for that spraying program.
53.25 – Us: So the spraying was funded by the national MoH?
Kota: No, mainly by the Japanes government. By the embassy of Japan and partly by
JICA, which is also a part of the Japanese government but different institution, and
PAHO.
52.55 – Us: We have read that JICA has mainly been involved in the chemical
control, the entomological investigation and surveillance, and the Information,
Education, and Communication (IEC) strategy to promote active community
participation, while the National Program had the responsibilities of the diagnosis
and treatment of the disease and the interruption of the transfusional transmission.
Why was this division of responsibilities chosen?
Kota: First of all we did not have medical staff on the Japanese side. So we could not
tackle the clinical part, the diagnosis and treatment of the patients. In JICA we had
experience with vector control in Guatamala, Honduras and El Salvador so we
decided to make the most use of our past experiences.
51.25 – Us: in the areas where JICA has been involved, how did the strategical
planning and prioritizing of the intervention function between JICA and the MoH?
Who decided the approach? Was is it something that was done in collaboration
between the two partners or was it JICA that has the experiences from the earlier
programs who designed the program? The priorities of the program, how were they
decided?
Kota: How do we set the priority on Chagas disease? In the case of Nicaragua. From
the view point of the MoH of Nicaragua Chagas disease was not one of the priority
issues. It’s not now either. The high level officer of JICA has a contact with Minister
of Health in Nicaragua and convinced them to start the Chagas disease project. I was
not involved in that negotiation so don’t know the details.
49.20 – Us: the responsibilities that JICA had in the project, how were these
responsibilities transferred to the national program?
Kota: From the outset of the project we understood that we as Japanese staff were
temporary resources. We would never work permanently in Nicaragua, so we never
sought to take over their job. The role of the Japanese staff was to assist the
Nicaraguan staff. That is it. So when the Nicaraguan staff did not work we did insist
they should do so. “This is you job. If you like, please do it. If not, it is not our
business. It is okay. So in that understanding we tried to see what kind of job was
most suitable for them.
47.45 – Us: Okay, but in what areas did you assist then? I guess JICA went into this
project with certain expectations and goals with the funds invested, so where did you
assist?
Kota: there are several areas. Fx we would assist the entomological survey. The MoH
of Nicaragua did not have any knowledge of how to conduct a survey on kissing bugs,
the Chagas vectors. They did not have any experiences. So we told them how to
program or conduct a survey. And then with the spraying technique we invited a
Japanese expert in the vector control to introduce a special spraying technique in
Nicaragua. And then we participated in the designing of the community based vector
survey and response system.
46.20 – Us: While in El Salvador we learned that there was a lot of focus in
strengthening communication between central, departmental, and regional levels of
the program. Was this also the case in Nicaragua?
Kota: In the case of Nicaragua, to make a sustainable program, we tried to strengthen
the communication between the central level, departmental level, and the municipal
level. Among three levels. I think the communication between the departmental- and
municipal level is very good but the administrative capacity at the central level is very
weak compared to El Salvador. So they cannot have enough control upon the
departmental level. That was very difficult for us also.
44.50 – Us: In what way do you mean the administrative capacity is weak compared
to El Salvador? Is it the information system or?
Kota: Yes, mostly the information system. Fx to administrate the vector surveillance
system, we should know how many bugs are reported and where, by which
communities. So, first of all, their municipality gather information and as they
consort(???) that information they report to the department. And the department
consort (???) all of the information to the central level. But this is not an automatic
way of reporting. If they don’t like to report or forget reporting that information flow
can stop. So we always need a pressure from the above. The departmental health
office is very effective to make that pressure and they can pick up the information
from the lower level. But at the central level we don’t have many resources, human
resources. There is just one person for Chagas disease and this person is covering
every kind of infectious disease so he does not have enough time. So he cannot make
sufficient pressure on the departmental level.
42.50 – Us: Did you say that JICA actually sought to strengthen communication
then? You point to that there is a problem between the central and departmental
levels of the program but did JICA seek to strengthen it?
Kota: Yes, we tried to establish the good communication between the different levels.
What we did was to elaborate, to write a national guideline to make the
responsibilities of each level clear. Or each health personal actually. Fx the health
director of the department should collect the information monthly and report it to the
central level. So we defined the responsibility of each health worker, of each level,
and we wrote it down in the national guideline. This national guideline was approved
by the Minster of Health so it was officially published but a document is document, a
text book is a text book in such country. I don’t know how much it is respected.
41.00 – Us: Would you say these functions could also be used in other health issues?
In other vector control programs or other places in the health system? This assistance
you have made, does it strengthen the system in general?
Kota: Yes, I think so.
39.45 – Us: You mentioned the national plan that you made and we also read that you
made a national Chagas operating plan, a technical standards and procedures
manual. What we actually want to know is whether these tools can be used in relation
to other diseases and how they could be used. Or the way of doing the work, doing the
national guideline is that an approach that can be used more generally?
Kota: We hope so but I am not so sure. Fx when I was in Nicaragua there was a
sudden outbreak of Spirosis, that kind of infectious disease that is mainly transmitted
by mice or rats. This was a sudden outbreak so there was no system to respond to that
outbreak but there was a very strong political will to control that disease and within
one year they were in control of the disease. The next year there was no outbreak and
there was no guideline, no document but they were able to react and make a response
system. So for Chagas disease we prepared a document, we defined the
responsibilities and functions but without political will it is just a piece of paper.
37.45 – Us: We have also read in the best practice by JICA that one of strategic
initiatives in Nicaragua has been the integration of entomological surveillance system
into primary health care. What were the benefits of this?
Kota: Just right now I am doing the analysis of that point. What were the benefits of
task shifting (I don’t think this is what he is saying but I don’t get it!) I say task
shifting because at the beginning we tried to construct the vector system just between
the community people and the vector control personal/staff. But there is not many
vector control personal in Nicaragua so they cannot manage all the reports from the
community well. So we integrated the medical and nursing staff into the primary
health care. They assist in reporting the bugs and in responding to the reports.
According to my tentative analysis the first benefit was to shorten the time gap from
the report of a bug incidence to the response. Before the task shifting it took around 34 months to make a response but after involving the PHC staff they were able to give
response within a month on average. So the responsiveness of the vector surveillance
system was improved.
35.20 – Us: You mentioned that the coordination and communication between the
municipal and the departmental level was actually pretty good and strong. How can it
be that response time was still reduced by 3 months if communication actually worked
well before?
Kota: Maybe there is some confusion. At the departmental level we have health
directors, epidemiologists, and administrative staff. They have power and a budget.
Under the departmental level we have the municipality where the vector control
personal is working. And then under the municipality we have the sector level and the
PHC staff is working at this level. So department, municipality, sector, and
community, there are four levels under the department. So the initial design of the
vector surveillance was between the community and the municipality, jumping the
sector level, but this design was not working well. So we integrated the PHC level,
the sector level, as an intermediate agent to support the reporting and response.
32.25 – Us: Another initiative made in Nicaragua has been the livelihood
improvements in preventing vector infestation in Madriz. We read in the best practice
that the main focus of this was to get the community member to get their beds in order
and to keep their animals out the houses and afterwards some community members
also planned to improve the walls in the houses with local materials. What were the
results of this and do you know if this project has evolved since JICA withdrew in
2014?
Kota: That is a good question. I think that strategy, we call it the ecological approach
because we don’t use a chemical, is still in the try-out phase. We cannot conclude if it
is good or bad. But we need to seek the best mix of chemical use and the ecological
approach, so there is great need for more research to develop a more effective
ecological approach. And in the case of Nicaragua, we tried to implement about 10
mini projects in each community where the community members can improve their
houses and their living conditions. Out of ten, and this is with our support, 8-9 worked
really well as they were able to improve their houses and so on. But I don’t know the
sustainability of these mini projects.
29.25 – Us: Did JICA give funding to improve the walls and roofs or was it mainly
focused in the behaviour of people in keeping the houses clean?
Kota: In the financial aspect we collaborated with the city hall, the majors… how do
you say… the political head of the municipality. So we talked to them and said we
need these construction materials like cement and JICA will pay half of it and the __
___ ___ pay the rest. In this way we made a financial cooperation. Improvements of
houses are very visible so politically it is a good way to convince and demonstrate the
political presence. So the city majors were very willing to cooperate in this project.
27.45 – Us: In you opinion, what is the scope of kind of project? Can it be applied on
a national level?
Kota: I think it is a little bit difficult because of the complexity of logistics. Compared
to the spraying for example, we can spray six to ten houses in a day using just one
sprayer. But to improve one house we need twenty persons in two or three days. So
the house improvements are time consuming and the results consuming, which means
that the scalability is very low. Scaling the ecological approach to the national level is
very challenging.
26.25 – Us: So you need 20 people to improve walls and roofs? And even though this
is time consuming do you think this approach has big potential benefits because it
would eliminate the habitat of the vector?
Kota: Yes, walls and floor. And yes, it has potential. You can say that using only the
chemical approach, the insecticide, we will never control Chagas disease vector. So
we need to invest our research capacity and our financial resources more in the
ecological approach.
25.25 – Us: We were also wondering what were the greatest benefits of the three-way
collaboration between the MoH, JICA and PAHO?
Kota: the involvement of PAHO was very important in the sense that we… Okay, to
start with PAHO made the core strategy at the regional level. As you know PAHO
and IBUCA, which is the regional initiative… In this initiative they have a shared
vision and shared country strategy but the PAHO don’t have financial power, so we at
JICA supported to materialize PAHO’s policies in each country. So we provided a
financial and technical support to make it work.
23.45 – Us: So PAHO’s role was mainly in making suggestions and not so much in
providing financial support and material or medicine maybe?
Kota: Yes, they provided drugs/medicines without cost but they did not provide
financial support as in for example spraying. They made a brilliant policy but often it
does not make sense because of the lack of financial resources.
22.45 – Us: What was the reason for choosing a disease specific approach in
Nicaragua and Central America instead of a more broad aim supporting the whole
health system? And what have been the benefits of this approach?
Kota: That is kind of historical, right? In the 1980’s JICA conducted a research
project for tropical medicine in Guatemala. And in this project the Japanese
researchers joint with the Guatemalan researchers invested (??) in Chagas disesase,
Malaria, Dengue fever and many other infectious diseases. In Chagas disease there
was a very important result so JICA wanted to move from the research to the practice
now based on that research product. That was the first motivation for JICA for
implementing the Chagas disease project in Central America. And as you know in
that time nobody talked about health systems and it was the Malaria era, which meant
that the vertical approach was the trend in that period.
20.55 – Us: And in your opinion are there also benefits in running the program
because of this very focused approach? Does it make it easier to show results and to
make a fast response compared to making and intervention more broadly focused and
more complex?
Kota: I think there is a benefit of a vertical program. As I said, we conducted the
spraying as a vertical program so it is easier for us to manage our resources, the
budget, and human resources. For example if we invest money in the Nicaraguan
country in a horizontal manner: okay, we have 1 million dollar here and you can use
this money to strengthen your health system. If I say so, they can use the money for
anything. They will start with buying new desks, vehicles and maybe pay out more in
salaries, which I will not pay. From this the results would be very meagre.
19.10 – Us: So it makes it easier to know that the money is actually spent well when
you have certain goals and aims from the start?
Kota: Yes. If you want to have better control of the money the vertical program is
better in such countries. You know about the high level of corruption in the Central
American countries, right? So we should be very careful in that sense.
18.40 – Us: So you think that this is one of the reasons for vertical programs being
better in Central America?
Kota, yes I think so. But we also realise the limitations of a vertical approach. We
could not manage the vector surveillance system very well, which needed to be
sustainable, just between the between the community and vector control personal. So
we needed to integrate the surveillance system intro the general health system, which
was a change from the vertical to a more horizontal or integration approach.
17.45 – Us: When we were in El Salvador we learned that, from MoH’s point of view,
one of the major benefits was that they had one information system where you could
enter information at the community level and then it would be possible to check this
information from a central level instantly. Do you think something like this would be
good to introduce in Nicaragua?
Kota: Yes, that is very necessary in Nicaragua.
17.00 – Us: You mentioned earlier that the project in Nicaragua drew on experiences
from the other programs in Central America. What experiences were you able to use
form these other countries in designing the program in Nicaragua?
Kota: First of all the spraying techniques and the spraying tactics. How many sprayers
can operate (???) and what kind of pit falls do we have in the field activities? We
learned this kind of field knowledge in Guatemala and we applied that knowledge in
other countries such as Nicaragua. Furthermore, from the experience of Guatemala we
noticed that the change from a vertical to a horizontal approach was very difficult. So
in the case of Nicaragua we started taking the vertical approach but we new that we
needed to change our approach in the middle of the project. Consequently we were
very prepared for this eventual change from the outset of the program. In the case of
Guatemala Japanese staff are very reluctant to change their approach from vertical to
horizontal because they loved the vertical working style.
14.45 – Us: Did the program cooperate with civil society organisations, religious
movements or organizations in Nicaragua?
Kota: In the case of Nicaragua we did not work closely with them. And we did not
work with any NGO’s either.
14.00 – Us: did you collaborate with any actors that were not part of the health
system? You mentioned the local governments and the Alcaldias. Did you work with
the local actors that don’t belong to the health system?
Kota: Just Alcadiez I think. Nicaragua is a very difficult country in the sense of
politics. Do you now the Sandinista? The very left movement. Many of the NGO’s do
not like the Sandinista government and most of the NGO’s have a liberal mind-set so
if/when we work with the NGO’s we should be very careful in order to avoid any
kind of political conflict. If you belong to the other parties, they do not want to
cooperate. Or if you are a Sandinista I do not work with you.
12.35 – Us: So there is a lack of will from both sides, both from the NGO’s and
government as well?
Kota: Yes.
12.25 – Us: We experienced in El Salvador that crime and gang crime was a huge
barrier in making a full scare intervention. Did you experience some of the same in
Nicaragua or what is the case there?
Kota: Nicaragua is a very safe country and compared to other central American
countries there is not gang crime. Especially in the rural areas there is no proof of that
sort of crime or violence.
11.35 – Us: You talked about earlier that there has been a lack of political will in
relation to Chagas. But JICA ended its involvement on Chagas in Nicaragua did you
feel that the MoH would be able to continue the efforts?
Kota: That is a very good point. It took us about six months to maintain that political
will but first of all the minister of health in Nicaragua (Vavari), she is very interested
in the poor, like Sandinista. To improve the poor’s living situation is a national
priority but the minster of health is not so interested in Chagas disease. For example
the first priority is maternal __ ___ and child health and the second one is dengue
fever. So these two problems are politically very evident and if they failed in
controlling these two issues then the health director and the health authorities will be
fired. But the Chagas disease program is not so highly rated at the political level,
which is why we are not so sure if they will continue it.
9.20 – Us: When you finished the program did you make some final evaluation? And
if so what kind of indicators did you use to evaluate the program?
Kota: JICA use the standard scheme for evaluation, which is used in all ODA of
assistance program __ ___. These have five points: relevance, effectiveness,
efficiency, impact, and sustainability. A part of this standard evaluation is that we
technically evaluate the level of vector house infestation and the level of performance
in the vector surveillance system. So we combine the administrative evaluation and
the technical evaluation.
8.00 – Us: What were the results of this evaluation?
Kota: From the administrative part by JICA the project was evaluated in a very good
sense. The major indicators were accomplished and there were no big problems.
Maybe I can look for the final report in English or Spanish for you? If I find it I will
send it to you. In a technical view point I just published one paper, which reported the
results of the spraying program, the vertical program. You can find it on the internet
and it was published and shared in December. And right now I am writing the main
results of the surveillance part, the horizontal part, summarising data from the four
years and it includes data from after the project was terminated as well.
05.50 – Us: In your opinion what was the major benefits of JICA’s involvement in
Chagas control in Nicaragua and why?
Kota: The most important one is that they now work for Chagas disease control.
Before JICA they did almost nothing in Chagas disease, it was untouched by the
Nicaraguan government, but with JICA they started to do something. So we believe
that JICA’s presence increased the priority of Chagas disease in Nicaragua a little bit.
04.45 – Us: And on the other hand, what do you think have been the major challenges
in relation to Chagas? And also for the MoH in the future, what will be the major
challenges?
Kota: In the long run the challenge is sustainability. Now the MoH knows what they
have to do to continue the Chagas disease control in Nicaragua but for several
reasons: they don’t have a budget, they don’t have time, or they don’t have enough
political will, the things will not work well. But I think it depends on them. If they
recognise that Chagas disease is a very big problem in Nicaragua then they are very
prepared to do something.
03.15 – Us: Finally, we would like to know if we there in your opinion have been
anything we did not cover in this interview? If there was something you find
important that we did not include?
Kota: For the moment I am okay.
Martin Cazenave interview (MSF)
Us: According to your experiences, to what extent were the inhabitants in
Monteagudo aware of the health risks related to Chagas disease when the project
started?
Martin: Well, first of all this is what we internally call third generation of chagas. The
first generation were vertical, 100% MSF. We basically did everything ourselves. It
was a period of learning to treat something new because we hadn’t done anything like
this before the first projects in Honduras, Guatamala and Bolivia. And we made a
name in that period we were able to start speaking about chagas because prior to that
we had no background to support what we were saying. The second generation was
integrated. They were basically the same thing but in MoH institutions. So it would be
one doctor from MoH and one lab technician MSF who would go together. This type
of project we experienced that this kind of project is very nice. It develops knowledge
but it hasn’t been demonstrated as a sustainable type of project. The minute MSF
leaves the activities shrink in to the same level as before the MSF intervention. So
what we proposed in this new generation, the third generation of projects here in
Bolivia, was something pretty new to us. This is a project where we expect everything
to come from MoH. We are there to support them and train them and to help them
organize themselves. But before starting the projects we did months of meetings to
agree what its counter-background would do. So we had to meet the mayors of … and
we had to meet the authorities and hospitals and the local level. We had to meet at the
departmental level to decide what we were going to do (we are going to do this but
not this as we did previously). If you agree to this we start the battle if you don’t agree
to this we don’t need to start. Everybody was fine with that because everybody was
requesting a strategy that could ‘leave sustainability’… my English is not as good as
my Spanish… that would be replicable. So we avoid something that is very common
in the MSF, which is to enact some sort of paternalism (Peter said it, but Martin
agreed). We say guys, look, there is a gap here and you need to fill it.
CONFUSION: he says something about sustainability and replicability but it is hard
to hear what he is exactly saying.
This project us not designed MSF style. It is designed more with a focus on
capacities. We grab what there is and we design a strategy to tell us (on the basis of)
what is available. We don’t say that in order for us to start the project you need do
that or you need to invest one million dollars. Rather lets see what you have and with
that we provide and we go ahead.
Us: But was there a strategy from first to second and third or was it basically a
lessons learned in the second generation that made you move in and act as you do
now in the third generation?
Martin: I think each generation was needed. Because the first generation made us
work/worry about chagas. The second generation could be considered as way for us
learn how the MoH work in Bolivia. An the third generation: we know how you work
so we will try to design a strategy knowing how you work. So I wouldn’t criticize
either of the steps, I would say each step was necessary and provided some
knowledge.
Us: I know it was the first generation of investigations that focused on making people
aware of the disease but what is the status of how people perceive the disease now?
Are people fully aware of how critical it actually is to society and how do people
recon it?
Martin: Well, this varies in different places. They know that they have to do a lot
more than they do. At country level, department level, and town level. They know
that this is an embarrassing part of their strategy in an endemic country. It is
something that is very pending and it is one of the activities we approach with our
counterparts, especially at the department level and national level to say guys, you
need to reinforce this area because it is amateur like.
Us: Okay, so that’s the attitude from the ‘system’. But how do the people postponed to
the disease perceive it?
Well, the consequences of what I said before are obvious in the knowledge of the
people. There is no strategy in information, education and communication. No
strategy at any level. The people in the rural areas … ignorance. In many places they
have alternative medicines - traditional medicines that produce new cases of Chagas.
I’ve heard examples of people putting the vector, the vinchuca, in a blender making a
juice, which the patient then drinks. Ridiculous things like that. Another frequent
thing is people going to the veterinarian asking for the same things that are given to
the cows or parasites and the ‘vets’ then give them these anti-parasitic medicines that
are not for humans. Basically there is a large cap in communication and knowledge at
the community level and in rural areas especially and even in the cities and major
towns. It’s a big, big deficit in Chagas.
Us: So many of the inhabitants in the rural areas they don’t know that the vinchuca
carries a disease? Or do they know that the disease comes in this way?
Martin: A lot of places they still don’t know. A lot of places that have domestic
animals, they have lived with these animals (vinchucas) their entire lives. In some
places, fortunately not anymore, but until 5-10 years ago you would find vinchucas all
over the house. They were like cockroaches. So it is hard for them to realise what this
insect is responsible for after living with these animals for a whole life. (14.50: says
something I cannot understand)
Us: You already touched how you started out with describing the different genrations
of projects. But before moving into the country and the site did you make any
entomological and epidemiological investigations?
Martin: If it has been part of our activities? Yeah. Our activities, practically from the
start, have been integral. Everything. I cannot remember a project without this
component included.
Us: In your opinion, has there been any conditions that are specific to Bolivia, or
Monteagudo, which affected the project? And how is it carried out with regards to
culture, geography, infrastructure, and ecology?
Martin: Look at it this way. I’ve been here for almost three years and I’m finishing in
three weeks and this has been exhausting. It is really a lot easier when something is
missing and you put it in (fix it). It is really a lot to expect the counterpart (MoH) to
provide. The project requires a lot of lobbying. The greatest threat has been that the
counterpart is very informal(??). Something very specific to Bolivia is that people
don’t answer emails. Even though its not really a part of what we should do, we send
a report every month to the counterparts. And I send this report to the leader of the
national program. Everybody at the department level, the local level, lavatories,
vector control – everybody. They do not ‘counterparts’ (18.50: Cannot decode what
he is saying but is probably that they don’t read it and do not respond). I send it every
month with a little note that I would like them to give the report to… In the last 5
months I received two emails.
19.30 - Us: I was actually wondering, the national Chagas program and the MSF
program do they have some kind of common coordination and where is the
coordination between the central, regional, and the municipal level? How does this
take place? Is there like a central strearing committee on a central level?
Yeah, you guys ask good questions. This is basically one of the big efforts of the
project. To see who does what and who is responsible for what? We don’t share
personal. Our personal is in (don’t get the word) and we are a very small team.
Basically a team of lobby and coordination, we are not hands on. This is the key to
our successful project in Bolivia. To mobilize everybody and to hopefully be
coordinated in a way so that nothing is missing because Chagas is multi component.
The national program is responsible for vector control and medication but then all
these people with cardiologic problems and intestical ___are not taken care of by the
national program. The national program doesn’t even know about them, it doesn’t
even have statistics of how many Chagas cardiologic patients there are. They have
nothing to do with that. So that is where the hospitals and the towns compliment what
the Chagas program is doing. The national program gives me the elements to do
diagnosis but if I see you and confirm the Chagas diagnosis to you I still need more
tests. But the Chagas program does not cover this. There are many people involved in
each of the areas. Even in vector control. The national programs give the product to
spray and some gasoline to the guys who spray. The municipality then gives clothes
and salaries. So one of the greatest difficulties in Chagas is to organize them like a
soccer team. You are here and you do that. To be complete you need all the players.
This is what is usually lacking and one of the challenges.
23.20 – Us: So in order for someone to get confirmed that he carries the disease and
has chagas how many actors are involved?
Martin: Just one.
Us: the diagnostic test, the stat pack, which you mentioned, who carries this out? Is
this municipal employees or?
Martin: No, that should be provided by the national program. It gives the town a basic
amount. If the town wants to diagnose more patients it will how to provide for itself.
The national program does not give an unlimited amount of stat packs. What I
mentioned before is that you can do that diagnosis and confirm it but to treat them
you need more tests. There is nothing useful in diagnosing if you are not going to treat
them. And to begin treatment you need more tests that are not provided by the Chagas
program.
24.50 – Us: So when you have a positive test from the diagnostic test that someone
has Chagas, how is medicine administered to these persons? I suppose you the test
and then its send somewhere and where does the medicine come from?
Martin: the program also provides the medicine. The national program sends it to the
departments who then send it to the towns. This medication is provided to the patients
on a weekly basis. The patient gets medication for one week and then comes back for
a check-up. It is provided in a way so you can control the possible complications or
adverse effects of treatment.
25.55 – Us: What we have read in MSF’s homepage is that one of the main goals, as
you also said, is the coordination of who is going to do what. This technical
assistance is that some kind of management strategy that you provide or do you some
kind of guidelines or specific things you teach the different actors?
Martin: No, I’d say we are basically … DO NOT UNDERSTAND
NÅET TIL 26.55
27.25 – Us: You mentioned the lobby work, which was very necessary. Who do you
work with in lobbying? Is it lobbying the national government, the local authorities or
who is it necessary to lobby these efforts to?
Martin: the town hall, the municipality, the hospitals, the program at department level,
the MoH, SEDES, the national program in the capital.
Us: How do they receive this? Do the receive it in a positive manner and do they
agree that this is something that needs to be improved or do you often find
disagreements between your goals and their goals. Is it easy this process?
Martin: We were called to do the provisions for the national protocols for Chagas.
And we were practically ___ this meeting. This was a really crucial meeting because
we were discussing the protocols for Chagas from 2007. So we insisted, we were the
main actors insisting on the update of the protocols. When they finally decided to do
the update we had whole week meeting in La Paz and I say this with complete
humbleness: we were the main actor in this workshop. Basically we were… they
listened to our input and we were very respected. At other levels it is a little more
complicated. Nobody has ever ‘hit the table’ (put their foot down?). Sometimes we
have needed to really hold them in their ears (keep a tight rein on them) and say “hey
guys, this is not what we said we would do. This is not going like we agreed and
because of that we are not going anywhere”. They did not react badly to this or
complain. At town level its much more political. There is something that I always
mention that is very useful. Many of these people: the major, the locals etc have
Chagas themselves. And if they don’t have it themselves they have a father or
grandfather that might be dying from it. You cannot underestimate the usefulness of
this, as it is affecting the decision makers.
33.00 – Us: How is that not shining through then? You say there are actually
problems in becoming effective and in ‘reaching the table’ (getting Chagas on the
agenda). Are people and decision makers seeing other problems or aspects as being
more important than being effective in fighting Chagas?
Martin: Well, you can be very concerned about Chagas but sometimes people are
not… people are lazy. People are thinking about something else or are not effective.
Many of the positions, especially at the department level are political. The program
director of Chuquisaca, the department, is a political position. To expect
professionalism from political actors is overestimated. The capacities, and this is my
opinion, are unfortunately not the best are filling the positions. This is kind of touchie
and I would take this extra officially __. People in Bolivia are… this is strange but
something you have to understand. The professionals that are dealing with these
things are not the best.
35.25 – Us: So, does the project have certain goals related to… of course we that one
of the goals is to strengthen the whole coordination but do you have specific goals or
a way to measure whether there have been improvements in the coordination? Do you
know how to measure how improvements have been made?
Martin: Yeah, we have a log frame for it and an expected outcome that people with
cardiologic problems can have access to attention to medical services. And that the
certain amount of people that request diagnosis get it. That vector control is efficient
and continuing. And we have goals in each of the components: diagnosis, treatment,
treatment of Chagas, and then treatment of what is called __ (don’t know the word)
treatment, which is the treatment of cardiologic and untestable(??) – other
complications with Chagas, and vector control. We have everything inside the
spectrum of the expected (something) and outcomes.
37.15 – Us: And with regards to the vector control, you said that it is people who are
hired by the government in our whatsapp conversation. Do you know if there is some
formalised way to conduct this vector control and some kind of register to say “we
have done vector control here and here”? Is there some way for you guys to know
where it has been conducted and some kind of follow up to these visits?
Martin: The strategy that we are strengthening exists. The strategy is that there is a
local leader who is in charge of detecting vinchucas. This leader is the person that
centralises the community when someone says there is vinchucas in my house. This
leader then sends a message to the vector control technicians and they should respond.
In an ideal situation, and ideal world, this would mean that the technician goes to the
house and spray. There are a lot of barriers in that. First of all the community is
looking. We can have our leader but the community, the mother and the father, is not
informed about the need to (spray I think) and then it won’t be very efficient. The
second is that the leader does (or throws – 40.00) the report. Or another is that the
leader sends the report but that the report does not arrive at the vector control
location. Some times it is end by a motorcycle that is going to town and this is (some
word I can’t hear). And the third is that the technician puts the reports in the drawers
– see you later, thanks, bye. It is pretty tough to be able to develop a better strategy
but this is the ideal strategy with this population that exists. So to address this
problem MSF has EMOCHA. EMOCHA is basically a program designed by John
Hopkins University that is used to do this whole process. Basically what it does is the
leader of the community sends an SMS with a code that is 3 letters and 3 numbers that
is the geographical coordinates of the house that is infested. Like a GPS. This SMS
enters the EMOCHA platform and marks a red house, which means a report/case of
infestation or vinchuca. The technician then sends a message saying when he will go
to the address of the report. When he sends this message the house turns yellow. And
when the technician goes and does the spraying he has to be geographically within
200 meters of the house to deactivate the yellow house. He has a smartphone and he
enters the information about the house: how many litters of spray and the day etc and
presses enter. The GPS then registers that he is present at the house and has responded
to the report. So what this does is avoid… I could be able to se live where the reports
are. I could see where the reports are being addressed and where the reports have been
addressed. I see green, yellow and red houses. If you see a map full of red houses and
no green then reports are not being efficient. So it is a complete platform with
smartphone that are given to the people who spray and computers to those who
monitor the responses to the reports. The person responsible for Chagas in the
department can basically see how many reports there are and see what responses are
given to them.
45.20 – Us: But this system is actually in place?
Martin: The system started in 2012. It is not working yet because it needed a lot of
readjustments with tele operators etc. It is about to finish, to be on the ground, as we
are speaking. It could be tomorrow or next week. There has been a huge delay on the
side of the counterparts. We waited something like 4 months for the tele operator to
sign a contract but is basically about to be launched. But not in the same place, not in
Monteagudo.
46.50 – Us: I have one brief question. The community leaders you mentioned are they
voluntaries or do they have some kind of formal position?
Martin: They are voluntaries. The leaders are voluntaries and that is one of the
problems we are having. The program does not send work without any incentive and
at the same time does even give them the basic elements to work because these guys
need to pick the vinchucas. __ ___ ___
47.45 – Us: And how are these voluntary leaders selected. Is it through a workshop or
how do you get in touch with these people?
Martin: It is done differently in different places, unfortunately. At the local level they
are not selected its more political thing. Sometimes they have no other use for the
community because they are people that have colleagues(??). You know it is not a
very beautifully done process this selection.
48.40 – Us: I was also wondering, the supply of medicine, how is this supplied? Do
you experience that there is sufficient medicine to the confirmed cases or do you
experience problems with the supply?
Martin: This is a big problem. The access to the medication in the world is a problem
because there are only two labs that produce benznidazole, one is in Brazil and one is
in Argentina. The lab in Brazil does not have the GMP required to be able to export
medication or to be accepted in Bolivia to administer. So now there is an __ ___ ___
The only lab that produces benznidazole, which is the main drug, is a lab in Argentina
called ELEA and the price is, of course, three times as much as the Brazilian. This is
purchased by the country and is supported by ___ ___, the American and that is
problem. They buy a lot less than what is needed so it is a tricky subject because you
cannot say that… there is definitely not enough to treat all the patients with Chagas.
That would be an immense and impossible amount of medication. Its like a tuck of
war. One requests more and program gets less. The amount requested by the
communities and the departments are not fulfilled.
51.00 – Us: Is there any way to prioritize between the cases or how is it chosen who
actually gets the medicine?
Martin: It’s a good question. There are priorities , which are children under 15.
Congenital cases of chagas, acute chagas, are all priorities. But other than that it is
“the ones in crisis” (I think!).
51.40 – Us: So the chronic cases a generally not treated if the person is over 15 or?
Martin: No, the protocol, the new protocol in Bolivia, although it is not published,
says that people up till 60 gets treatment. Until a few years ago it was under 15 but
now it is under 60 so the priorities are clearly…
52.40 – Us: So another thing we want to know a bit about is the educational efforts. Is
it a part of the project to do workshops in schools or in areas of the communities?
Martin: Yeah, this is a part of the project that needs to be developed. It is being
addressed but what was done before MSF like posters have… We have to be coherent
with this kind of project. We want them to design these things. Maybe we support
with a little bit of something ing. But we don’t want to do the whole thing so what we
are doing now is trying to gather the actors and “OK guys, you need to do this. Who
is going to do it and how?” But we are not going to do it, you guys are going to do it.
54.00 – Us: Do you experience that the communities actually do it or is that what
need to be developed, that you need to foster a more collaborative effort?
Martin: Well, it’s a completely missing issue (not being taken care of). We have two
battles now today: one is making Chagas association in the town. This is always
helpful to ‘make the match’?? It’s like a union. So it’s a semi political thing to put
pressure on the actors. This association is also very delicate because you want people
to gather but the first step crucial, which is to avoid creating something that is really
doing nothing. Because this is what is going on in other associations (mentions some
regions). The people that are leading these associations are old people with no
initiative. You really want to create something that is going to work and is going to
put pressure on the counterparts (I think). This is the one battle. The other thing we do
is on the radio and TV to gather Chagas patients to the first meeting and see how they
develop the association. The Chagas patients association. We need to reinforce
because 10 or 15 people showed up and it was not what we needed. We needed to
work it out a bit more. This is a ‘one side’, the association that we thing will be a
good part of the ‘whole thing’ (the project?) and the other part is about the education,
information and… what we are going to do is basically start trying to see who wants
to participate. We already have … to contact a specialist. Not to develop a strategy
but to help them develop it. It’s different.
57.35 – Us: You mentioned on Whatsapp that it would be a good thing to find
chemicals that is more harmless when conducting vector control. What are the
consequences of the chemicals used right now?
Martin: We don’t experience, or I haven’t heard of any problems, but it would be
fantastic to be able to just drop a pill inside the house so there would be no need to
contact a vector control technician. If we had these things they have for mosquitos
where you plug something in and the mosquitos disappear we wouldn’t need to whole
system. The existing materials used are toxic and need to be administered.
59.40 – Us: When a house get sprayed what kind of consequences are there for the
inhabitants. Do they need to leave their house for period of time or what is required?
Martin: This is not my expertise but the sprayers need to evacuate the house for hours,
not days. The pesticides/chemicals used are not extremely toxic but ‘would need to
ask a professional (I think?).
1t 44 sek – Us: When a house gets sprayed how long can there go till can become
reinfested?
Martin: The spraying is not a miracle. Sometimes the bug can be found again the day
after you have sprayed. It’s really good but it is also very operator dependant. You
need to be very ‘obsessive’ of how it is done (careful with using it too much, I think).
Sometimes these vector control technicians have problems with alcohol. It is not
unusual to encounter these kinds of problems. So you can imagine that we have seen
fx people (VC technicians) arriving not being able to drive a motorcycle.
1t 2min – Us: anything important we did not cower in the interview?
Martin: No. I am surprised by the level of knowledge here. This is a very complex
issue, even for people who have been in the ‘issue’ for a long time. I am really
surprised by the level of knowledge you guys have 