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Master Document Template Copyright by Kristin Cheasty Anderson 2014 The Dissertation Committee for Kristin Cheasty Anderson certifies that this is the approved version of the following dissertation: Health Care Reform in Sandinista Nicaragua, 1979-1990 Committee: Virginia Garrard-Burnett, Supervisor Ann Twinam Charles R. Hale Anne Martínez Renata Keller Health Care Reform in Sandinista Nicaragua, 1979-1990 by Kristin Cheasty Anderson, B.A.; M.A. Dissertation Presented to the Faculty of the Graduate School of The University of Texas at Austin in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy The University of Texas at Austin August 2014 Dedication This dissertation is dedicated to my husband, without whose steadfast support I never would have been able to finish this project, and to my daughters, who I hope will one day set themselves to achieving marvelous things. Acknowledgements I wish to acknowledge the invaluable contribution of several people who helped me along this path, and without whose contributions this project would have either suffered or fallen by the wayside. At the University of Texas at Austin, I owe a great debt to both my advisor, Dr. Virginia Garrard-Burnett, and Dr. Ann Twinam. Dr. Garrard- Burnett has been relentless in her support, urging me on with her enthusiasm for the topic, and her belief that this project matters. Her bottomless knowledge of Central America during the twentieth century is both an inspiration and an invaluable resource. I wish also to thank Dr. Twinam, who over the years of graduate school (with rigorous application of red ink and ALL CAPS) taught me the finer technical points of writing well. If in this dissertation you find instances of the passive voice or topic sentences that don’t directly lead the reader, they are entirely a product of my own inattention to detail. I am also greatly indebted to the people of Nicaragua. In particular I wish to thank Dora María Tellez, who served from 1985 to 1990 as the third Minister of Health under the Sandinista government. Her willingness to answer last-minute questions in great depth of detail (even in the midst of earthquake recovery in 2014) helped fill in the gaps left in the oral history and documentary records, and made it possible to write with precision and confidence. Most of all, however, I wish to thank the people of Matagalpa and the Mountainous North, who were willing to answer bizarre questions from a gringa who appeared out of nowhere asking about health care. v Health Care Reform in Sandinista Nicaragua, 1979-1990 Kristin Cheasty Anderson, Ph.D. The University of Texas at Austin, 2014 Supervisor: Virginia Garrard-Burnett This dissertation explores the health care system built by the Sandinista government in Nicaragua between the years 1979-1990. Prior to the 1979 victory of the Sandinista revolution, Nicaragua had a limited, balkanized health care system that afforded access to care to only a small percentage of the Nicaraguan population. The Sandinistas sought to build a nationwide health care system that provided free and equal access to health care. This project is a study of how the Sandinistas did that, and an analysis of what success they had. This project relies upon new sources as well as established archival ones. Former Minister of Health Dora María Tellez (1985-1990) recently donated her personal collection of Actas Ministeriales (Ministerial Executive Orders) to the Universidad de Centroamérica’s Instituto de Historia de Nicaragua y Centroamérica (IHNCA), a cache that substantially increases the documentary record of the latter half of the 1980s, and thus expands our understanding of the issues at hand and the solutions the Ministry implemented. Also, this dissertation relies heavily upon oral history. Seventy-five vi interviews with Ministry leaders, health workers, and Nicaraguan citizens create a more personal history of health in Sandinista Nicaragua, and explain how this nationwide effort actually functioned in communities, both urban and rural. The five chapters of this dissertation explore these central questions through multiple lenses. The first chapter provides both a history of foreign intervention and of history of health care in Nicaragua. The second and third chapters explore the historical trajectory of the Ministry of Health during the eleven years of Sandinista rule, first at a national level, and then with a focus on the northern zones of Nicaragua. In the final two chapters the dissertation explores the international angle of this history. The fourth chapter looks at the important role Cuban foreign aid played in helping the Sandinista government build, supply, and maintain their health care system. The fifth and final chapter interrogates the presence of long-term volunteer health care workers from the United States in light of the fact that the U.S. was leading efforts to overthrow the Sandinista government throughout the 1980s. vii Table of Contents List of Illustrations ...............................................................................................................x Introduction ..........................................................................................................................1 Methodology ......................................................................................................3 Literature Review...............................................................................................8 Organization .....................................................................................................13 Chapter One: History of Nicaragua and Nicaraguan Health Care .....................................17 Geography ........................................................................................................21 History up to the Somozas ...............................................................................23 The Somoza Dictatorship(s) and the Rise of the Sandinista Revolution .........33 Health Care in Nicaragua Prior to 1979 ...........................................................38 A Post-Revolutionary Health Profile ...............................................................50 Conclusion .......................................................................................................52 Chapter Two: Socialized Health Care in Sandinista Nicaragua, 1979-1990 .....................55 Cesar Amador Kuhl: Collaboration and Rebuilding (1979-1980) ...................57 Lea Guido (1980 – 1985) .................................................................................70 Dora María Tellez (1985-1990) .......................................................................92 Conclusion .....................................................................................................115 Chapter Three: Matagalpa and the Mountainous North ..................................................119 Matagalpa: A Brief History ...........................................................................122 Health Care in the Mountainous North ..........................................................130 Health Care Infrastructure ..............................................................................133 Community Organizing .................................................................................148 Adaptation to War: Crisis Management ........................................................155 Health in the Mountainous North ..................................................................166 Political Imediments to Health Delivery ........................................................172 Conclusion .....................................................................................................183 viii Chapter Four: Doctors Within Borders: Cuban Medical Diplomacy to Sandinista Nicaragua ................................................................................................................186 Global impact of Cuban aid in light of the Cold War. ...................................192 Intra-regional relationships in Latin America during the Cold War period ...195 Cuban medical diplomacy to Nicaragua: National and regional ...................197 The Cuban experience: A personal story .......................................................207 Matagalpa: A case study ................................................................................209 Voices in opposition ......................................................................................218 Conclusion .....................................................................................................221 Chapter Five: In Solidarity: Americans and other Foreign Nationals in Nicaragua, 1979-1990 ...............................................................................................................224 Who were the Solidarity Workers? ................................................................235 Why Did They Go To Nicaragua? .................................................................236 What Did they Do in Nicaragua? ...................................................................244 How Did Nicaragua Utilize These Volunteers?.............................................249 What Impact Did Solidarity Workers Have on Health Delivery and MINSA? ................................................................................................252 How Did Nicaraguans View the Solidarity Workers? ...................................258 Solidarity Workers’ Impact at Home .............................................................262
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